Oncology & Hematology Coding Alert

Reader Questions:

Be Consistent With Coding Suspected Diagnoses

Published on Fri May 26, 2023

Question: A patient presented to the office with a painless lump behind their ear. Our provider aspirated the mass 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?

Nevada Subscriber

Answer: In this case, you should report the diagnosis as R22.1 (Localized swelling, mass and lump, neck). While tempting, you should not code this as confirmed pilomatrixoma using 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 Section II.H of the official ICD-10-CM guidelines added “compatible with” and “consistent with” to the list of terms that indicate an uncertain diagnosis. Although pathology reports should no longer include those terms when stating a final, definitive diagnosis, providers 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, the physician — or you, if appropriate — may consult the pathologist for clarification. Where the pathologist intended the report to conclude a definitive determination, training may be required to explain that documentation using those terms can impact coding, treatment, and billing if that was not the intended message.