Deanna Posted Sun 22nd of October, 2017 14:19:00 PM
We come across situations where a shave excision is performed on a lesion, but the path report returns showing the lesion is malignant. Since the CPT range for shave excisions falls under the Benign Lesion policy for Medicare, using the malignant dx results in denials for not having a covered diagnosis. I tried to appeal one denial a while back and the denial was upheld. Is it correct to use the malignant dx code from the path and not the dx provided by the provider (since the malignant dx is not know at the time of the procedure) for more specificity, even though the CPT is not based on being benign or malignant? Thanks in advance!
SuperCoder Answered Mon 23rd of October, 2017 02:36:25 AM
The intention of your doctor was to perform shave removal of the lesion and that was the procedure which was actually performed. In this case, you can only report code for shave removal of the lesion only because the nature of the lesion cannot change the procedure performed.
Moreover, malignant lesion cannot be removed by shave excision because it is required to remove the lesion and a margin of normal tissue to remove the malignant lesion completely.
Insurance may not pay for shave removal of malignant lesion. Please ask for clarification from the clinic (or doctor).