Ob-Gyn Coding Alert
Base Dx on Path Findings
Question: What diagnosis code should I use for a colpopexy and endometrial biopsy based on an abnormal finding on pathology from a previous dilation and curettage (D&C)---exocervical--type squamous epithelium with changes suggestive of low-grade intraepithelia lesion (mild dysplasia) Ki-67 and p16 immunostains support possible low-grade dysplasia-? The ob-gyn used 795.03 for the electronic medical record, but that refers to a Pap.
Tennessee Subscriber
Answer: You are correct that you should only use 795.03 (Papanicolaou smear of cervix with low-grade squamous intraepithelial lesion [LGSIL]) for a Pap result that shows low-grade squamous epithelial lesions. ICD-9 code 795.03 is not a histologic diagnosis, but rather a cytologic diagnosis. Because the path result was the result of a histologic examination, you should base your code on these findings.
On the other hand, the path report does not say unequivocally that she has mild dysplasia, but rather suggests mild dysplasia. Consequently, you should go with 622.10 (Dysplasia of cervix, unspecified) rather than 622.11 (Mild dysplasia of cervix).
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