When to Use 'Uncertain Behavior Diagnosis Code'?

Published: 09th June 2011
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You may be in for a great loss if you always use diagnosis code 238.2 while reporting 11100 for a biopsy procedure your surgeon performs. The best way to know when to use the 'uncertain behavior' diagnosis code is understanding what that code descriptor really means.


Here are some expert tips to ensure you are zeroing on the correct diagnosis code for all your 11100 claims:


a) If your general surgeon carries out a biopsy, make it a point to wait until the pathology report comes back to select the proper diagnosis and procedure codes to report even though this will not always affect the CPT code you'll wind up choosing.


Here's why: The biopsy specimen's pathology will have a say on the ICD-9 code you report. However, most CPT procedure codes are not based on the specimen results. There are certain CPT codes which are linked to some specific diagnoses; however in totality CPT is about what you did; while ICD-9 is about the outcome or the reason for it.


You should know the Meaning Behind 'Uncertain' Codes when you code 238.2 as the diagnosis for a biopsy procedure, you're conveying to the payer what the pathologist said in his path report that he was uncertain as to the morphology of the lesion. Uncertain behavior does not mean that the coder is uncertain or that the doctor thinks the lesion looks suspicious but it might be benign. By Uncertain behavior we mean to say that a specimen has been examined by a pathologist and that the cells are of mixed types.


How it functions: Uncertain behavior diagnoses are proper 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 doesn't actually have or may have however has not yet been corroborated. If you aren't sure as to what a lesion is, you use unspecified, not uncertain. Uncertain is reserved for a pathologist only diagnosis.


b) Secondly, you should never code just to ensure you will be paid for a procedure. In an instance of a biopsy, waiting to code until you have the pathology report shouldn't have a say on your reimbursement amount anyway. You may have to wait for some more time 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'd use so it's a perfectly payable diagnosis. On the contrary, insurers are looking for more and more reasons to deny payment. If you had carried a biopsy and indicated that the patient has hyperplasia and then the doctor 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.


For more on this and other information relating to ICD-9 codes, sign up for a one-stop medical coding guide like Supercoder.


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