Do Away With 'uncertain Behavior' Confusion With These Expert Tips

If you always use diagnosis code 238.2 when you are reporting 11100 for a biopsy

procedure your dermatologist carries out, you are leading your practice up for a disaster. The key to knowing when to use the 'uncertain behavior' diagnosis code understands what the code descriptor really means. Here are some expert tips to ensure you are choosing the right diagnosis code for all your 11100 claims.

Wait for pathology prior to selecting a code

When your dermatologist carries out a biopsy, you should always wait until the pathology report comes back to choose the right diagnosis and procedure codes to report even though this will not always affect the CPT code you will wind up choosing.

Reason: The biopsy specimen's pathology will have an impact on the ICD 9 code you report; however most CPT procedure codes are not based on the specimen's results. There are some CPT codes which are linked to specific diagnoses (example, excision of benign and malignant lesions), however overall CPT is about what you did; and ICD-9 codes is about the outcome or the reason for it.

Know the meaning behind 'uncertain' codes

When you report 238.2 as the diagnosis for a biopsy procedure, you are telling the payer that the pathologist said in his path report that he was not sure as to the morphology of the lesion. Uncertain behavior does not mean that the coder is uncertain or that the physician thinks the lesion looks suspicious but it might be benign. It means that a specimen has been examined by a pathologist and that the cells are of mixed types.

How it functions: Uncertain behavior diagnoses are right for specimens identified as hyperplastic (hyperplasia) or precancerous. If you submit a claim with 238.2 as a diagnosis before you have the pathology report back, you may have in actuality told the insurer that the patient has a disease process that he does not actually have or may have but has not been confirmed as yet. If you are not sure what a lesion is, you can use unspecified, not uncertain. Uncertain is reserved for a pathologist only diagnosis."

Do not rush coding just to get paid

You shouldn't code just to ensure you will get the payments for a procedure. In the case of a biopsy, waiting to code until you have the pathology report should impact your reimbursement amount anyway. You may have to wait a bit longer to see the payments if you need to hold a claim while you wait for the pathology report; however your coding will be much more accurate. If you biopsy a lesion and the results come back as precancerous, this is exactly the diagnosis you would use so it is a perfectly payable diagnosis.

On the other hand, insurers are looking for more and more reasons to reject payment. If you had performed 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 trouble.

by: James Article

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