Pathology: Don't Rush Your Coding Just To Get Paid

By Author: James Smith
Total Articles: 206
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You should never code just to ensure you will be paid for a procedure. In the case of a biopsy, waiting to code until you get the pathology report should not affect your reimbursement amount anyway. You may have to wait a bit longer to see the reimbursement if you need to hold a claim while you wait for the pathology report, however your coding will be much more spot on.


If you biopsy a lesion and the results come back as precancerous, this is exactly the diagnosis you would use it so it's a perfectly payable diagnosis. On the other hand, insurers are looking for more and more reasons to deny payment. If you had carried out a biopsy and indicated that the patient has hyperplasia and then the physician found out that the biopsy indicated melanoma and the patient returned to have excision of the melanoma and the insurer ever compared the documentation there could be problems.


Furthermore: If you report the service with 238.2 but the patient actually has a benign lesion, you run the risk of having to repay ...
... the insurance company during an audit. Should the payer ever look closely at your surgeon's documentation, they could require repayment based on the fact that the rules for coding and billing benign lessons are quite different from the rules for billing for treatment of precancerous lesions. They might feel that you were using the diagnosis of neoplasm of uncertain behavior in an effort to establish medical necessity for services that might otherwise be considered cosmetic.


A payer could in actuality bring a practice up on charges (civil or criminal) for coding the ICD-9 improperly since it is what determines the medical necessity for payment from the payer.