Oncology & Hematology Coding Alert
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: You can use diagnosis code D49.4 (Neoplasm of unspecified behavior of bladder). This is because your provider hasn’t yet specified if the neoplasm was malignant. This code represents the confirmation of diagnosis due upon receiving the final pathology report.
Note: When the biopsy report confirms a malignancy, you can submit C67.2 (Malignant neoplasm of lateral wall of bladder).
Oncology & Hematology Coding Alert
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