General Surgery Coding Alert

Question: In the office, our surgeon aspirated a painless “lump” behind the patient’s ear and submitted the fine needle aspirate for pathologic diagnosis. The pathology report stated that the cellular material was “consistent with” Pilomatrixoma. How should we code the diagnosis?

Iowa subscriber

Answer: You should report the diagnosis as R22.1 (Localized swelling, mass and lump, neck). You should not code this as confirmed pilomatrixoma (D23.4, Other benign neoplasm of skin of scalp and neck)

Here’s why: For outpatient services, ICD-10-CM Official Guidelines, Section IV.G, states, “Do not code diagnoses documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ ‘compatible with,’ ‘consistent with,’ or ‘working diagnosis’ or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.”

Effective Oct. 1, 2019, an update to the guidelines added “compatible with” and “consistent with” to the list of terms that indicate uncertain diagnosis. Although pathology reports should no longer include those terms when stating a final, definitive diagnosis, they sometimes still use the terminology.

Do this: Your responsibility as a coder is to assign the correct codes based on the words in the provider’s report. Based on what you’ve included in your question, you should report R22.1, not D23.4.

Alternatively, you may consult the pathologist for clarification — and possibly a discussion about documentation using those terms impact coding, treatment, and billing.