General Surgery Coding Alert

Question: When one of our surgeons removes a breast mass, he insists on putting the diagnosis in the op report "uncertain behavior neoplasm, breast" if the pathology report is not back. When is it appropriate to use this diagnosis, as opposed to "breast mass?"

Texas Subscriber

Answer: You should not use an uncertain behavior code, such as 238.3 (Neoplasm of uncertain behavior of breast), unless the surgeon has reviewed the pathology report and confirms that the neoplasm meets certain characteristics. In the scenario you describe, a code such as 611.72 (Lump or mass in breast) would be more appropriate. It's best to wait for the pathology report and assign a final diagnosis.

Uncertain behavior codes are appropriate when the pathologist identifies a neoplasm that exhibits characteristics indicating that it might become malignant. If the tumor has an unpredictable behavior, it then fits in the neoplasm of uncertain behavior category. ICD-9 describes these tumors as "histomorphologically well-defined neoplasms, the subsequent behavior of which cannot be predicted from the present appearance."

Coder tip: Don't use "uncertain behavior" neoplasm codes when you're uncertain about the diagnosis -- save it for when the pathologist determines that the neoplasm's behavior is uncertain based on current evidence.