Pathology/Lab Coding Alert

Don't let 238/239 confusion leave medical necessity to chance.

You may feel "uncertain" when selecting a neoplasm code for a pathology report -- but that doesn't mean the lesion is uncertain.

Mistaking "uncertain" for "unspecified" could cost you, based on payers' covered diagnosis lists that impact medical necessity decisions. Take a look at our experts' explanations and examples to make sure you know the difference.

Know the Big Picture

To understand the uncertain/unspecified distinction, you need to comprehend the overall neoplasm diagnostic classification scheme. The ICD-9 neoplasm table distinguishes cancers as malignant, benign, uncertain, or unspecified.

Let's start with the malignant/benign difference, because that's the key to understanding the "uncertain" classification. "Malignant neoplasms are cancerous, and may be noninvasive (in situ), or invasive," explains R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark.

ICD-9 further subdivides invasive cancers as "primary," meaning that the cancer arises from surrounding cells, or "secondary," meaning that the cancer metastasized (spread) from a primary malignancy located elsewhere in the body.

Depending on location, ICD-9 distinguishes the cancer types with different codes. For example, for the female breast areola you would choose from the following codes:

• 174.0 -- Malignant neoplasm of female breast, nipple and areola

• 198.81 -- Secondary malignant neoplasm of breast

• 233.0 -- Carcinoma in situ of breast.

Benign neoplasms are cancer-free. For example, for a fibroadenoma of the breast, you should report 217 (Benign neoplasm of breast).

Tip: Don't report every benign neoplasm using the general benign neoplasm code for that body site, such as  219.x (Other benign neoplasm of uterus). "Choose the code based on the specific description from the pathology report, such as fibroid tumor as 218.x (Uterine leiomyoma)," says Melanie Witt, RN, CPC, COBGC, MA, a coding expert based in Guadalupita, N.M. Make Certain It's Uncertain Benign and malignant aren't the only neoplasm classifications available. "Sometimes the pathologist identifies a neoplasm that is currently benign but exhibits characteristics indicating that it might become malignant," Stainton says. Because the tumor has an "unpredictable" behavior, it fits a category called "neoplasm of uncertain behavior." ICD-9 describes these tumors as "histomorphologically well-defined neoplasms, the subsequent behavior of which cannot be predicted from the present appearance."

Uncertain is not unspecified: "Neoplasms of uncertain behavior have very specific histology that the pathologist describes," Stainton says. They are not unspecified.

Recognize key words: If the pathology report indicates atypia or dysplasia, the neoplasm is "in transition" from benign to malignant and is therefore "uncertain." If the process continues and the mass goes untreated, the neoplasm could eventually become malignant.

Example: Tubular adenomas of the colon are at risk for becoming malignant. If the pathology report mentions other biopsy conditions, such as high-grade dysplasia, you could report 235.2 (Neoplasm of uncertain behavior of stomach, intestines, and rectum).

You'll find the codes for uncertain behavior in the following ICD-9 categories:

• 235 -- Neoplasm of uncertain behavior of digestive ad respiratory systems.

Reserve Unspecified for Minimal Information

When the pathology report doesn't confirm a specific type of neoplasm -- benign, malignant, or uncertain -- you should report an unspecified code.

For instance: You'd use an unspecified code if you're billing before you have the biopsy results or when the pathology report does not contain enough information to select a more specific code. "Unspecified" indicates that the pathologist did not reach a specific diagnosis, possibly due to an inadequate specimen.

ICD-9 provides "unspecified" codes in category 239 (Neoplasms of unspecified nature).

Coverage alert: Many payers have policies that provide lists of covered diagnoses. Many of these medical necessity policies include codes from category 238 but not from category 239.

Follow These Steps to Pick the Right Diagnosis

"You should not use an uncertain or unspecified code when you -- the coder -- are uncertain," Witt says.

"Don't simply flip to the neoplasm table and select a code from either of these columns."

Do this: Instead, you should use the alphabetic index to look up the name of the tumor or available diagnostic information. The index directs you to the appropriate column in the neoplasm table. For example, if you look up "tumor" in the ICD-9 alphabetic index, it states, "see also: neoplasm, by site, unspecified nature."Before assigning a final code, verify the diagnosis you have selected in the tabular index. The tabular list provides additional information that you won't find in the alphabetic listing or neoplasm table. For instance, a specific category might show a list of terms that the code "includes" or "excludes." Here you may find a term that you see in the pathology report, which helps you confirm an accurate diagnosis or avoid a wrong one.

Tip: "Includes" lists aren't exhaustive, so if a term in the index directs you to a code, that's the correct code even if the term is not in the inclusion list.