General Surgery Coding Alert

Question: Our surgeon excised a “lump” from a patient’s right forearm based on a request from the general practitioner stating that the patient had a “mass.” Should we code the unspecified mass as the diagnosis?

Iowa Subscriber

Answer: Waiting for the pathology report and coding the final diagnosis is always preferable to reporting an unspecified diagnosis code based on signs and symptoms.

You don’t state the final diagnosis, but if the pathology report returned a diagnosis of “lipoma,” for instance, you should code the diagnosis as D17.21 (Benign lipomatous neoplasm of skin and subcutaneous tissue of right arm).

If you don’t have a final diagnosis, an appropriate code based on the requesting physician’s diagnosis is R22.31 (Localized swelling, mass and lump, right upper limb).