ICD 10 Coding Alert

Question: The pathology report for a urinary bladder specimen simply states “neoplasm” as the diagnosis. Should I code the diagnosis as D41.4?

Mississippi Subscriber

Answer: No, you should not code the case as D41.4 (Neoplasm of uncertain behavior of bladder). The term “uncertain behavior” is a specific designation about the tumor, just as “benign” and “malignant” are. If the pathology report doesn’t specify that the tissue exam reveals characteristics of “uncertain behavior,” these codes designating “uncertain behavior” are not supported.

Instead, the correct code for the case is D49.4 (Neoplasm of unspecified behavior of bladder). Unspecified means just that: the pathologist didn’t specify if the tumor was benign, malignant, or of uncertain behavior.

Better: You may ask the pathologist for clarification and then report a more specific code.