Wiki NGS denials on benign lesion removals

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NPSDEB

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In our practice, we remove suspicious lesions then send them to pathology. Once the path report comes back, we bill for the removal using benign or malignant lesion CPT codes. In the past when WPS was the Medicare carrier, they paid benign lesion removals. We are finding with NGS, their LCD is too restrictive and we are struggling with a high rate of denials. To be clear, these are lesions that our physicians are not removing for cosmetic reasons ? they are being removed because they are suspicious but end up being benign.

Is anyone else having this same issue and how are you resolving it. :confused:

Thank you for any and all help!!
 
when the path shows a benign result you can use a V71.1 first listed and the benign dx second. The V71.1 is for observation for a suspected malignant neoplasm not found.
 
Debra-
V71.1 looks like a good choice but it is not on the list of covered codes for NGS's LCD. That is where we are running into the problem....
 
I have used it when it is not specifically listed on an LCD and it works. If the LCD is worded to say dx codes such as and then lists dx codes, that means to include other dx codes in the same vein as those listed. Looking for a malignancy not found can be argued to be the same medical necessity as finding a malignancy.
 
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