Oncology & Hematology Coding Alert

Reader Questions:

Biopsy Alone Confirms Diagnosis of Malignant Bladder Tumor

Question: Our oncologist treated a patient for suspected bladder cancer. The diagnosis documented was ‘adherent, stone like structure with calcification affixed to the right lateral bladder wall, measuring 1-2mm.’ The biopsy report is still awaited. Which ICD-10-CM code can we report this diagnosis?

Arizona Subscriber

Answer: Assign diagnosis code D49.4 (Neoplasm of unspecified behavior of bladder). The provider nor the pathology report has not yet specified whether the neoplasm was benign, malignant of uncertain behavior.

NOTE: Under ICD-10-CM, as in the previous version, you may not report a neoplasm of uncertain behavior. The reason is without the pathology report specifically indicating the neoplasm is deemed to have characteristics of uncertain behavior, the code is not supported.