# Uncertain vs. Unspecified Neoplasm



## melwalters (Nov 14, 2012)

I have to code a polyp that was removed and I don't have the path report yet.  Should I use a code from the "uncertain behavior" category or "unspecified" category?  I know that waiting for the path report is best in order to code to the highest specificity but my doc wants to get the claim out.


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## mitchellde (Nov 14, 2012)

you cannot use 238.x codes for uncertain behavior without a path report.  The use of the 239.x codes for unspecified is for when a preliminary diagnostic study documents this is a tumor, or growth, 239.x codes are to be used when there is further work up to be done to determine the specific pathology.   You can code as a polyp or wait for path.


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## juliedurfee (Nov 14, 2012)

*Polyp without Path*

As one who codes the path reports, you should use 239.0 (unspecified gastrointestinal tract) and/or code the presenting symptoms (rectal bleed 569.3, diarrhea 787.91, personal history of polyps V12.72) or whatever your patient's presenting symptoms warranting the polypectomy are.  At least that's what I do.


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## HDaniels (Nov 19, 2012)

"uncertain behavior" is to be used when the PATHOLOGY REPORT states there is precancerous cells.  A code from "unspecified" is appropriate when there is no pathology report.  You didn't state where the polyp is, so I couldn't suggest a code, but I am sure of the ucertain vs unspec.  
I recently finished the AAPC prep course for the CPC and that was one of the things I wanted to be very sure of so I noted it in my code book


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## mitchellde (Nov 19, 2012)

Coding clinics and the CDC state that unspecified (239.x or D49.x) Is to be used after a preliminary diagnostic workup specifies the diagnosis as a "tumor" or a "growth"  If you have a dx of a polyp then that is what you should code, look up the term polyp and then location. if it is a rectal polyp then code for that if it is an intestinal polyp then code that, you do not have the documentation for an unspecified neoplasm and you do not have a path report for uncertain behavior


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