Pathology/Lab Coding Alert

Look up behavior first.

When your pathologist evaluates a breast specimen, you don't have a prayer of assigning an accurate diagnosis code if you can't extract certain information from the path report.

Use the following narrative diagnosis to master the steps you'll use to pick the correct breast ICD-10 code, every time:

Diagnosis - 72 year old female patient, history of breast cysts, invasive papillary carcinoma, right breast, 1 o'clock.

Focus on Current Condition

Ambiguity within a dictation report is one of the most fundamental problems pathology coders face. You need to center your code choice on the clinically significant condition. You also need to assign the most specific code possible, which becomes increasingly difficult as the number of characters within a diagnosis code increases. That's one of the reasons some coders find neoplasm coding so difficult.

There are a few scenarios that coders should be especially wary of when it comes to ambiguity. For instance, "coexisting conditions and historical conditions should only be reported if they are related to the current management and treatment of the patient," explains Amanda Corney, MBA, medical billing operations manager for Medical Resources Management in Rochester, New York.

That means in this case, you do not need to assign a code for history of breast cysts. Nor do you have any indication from the pathology report that the breast tumor is metastatic from another site. That information comes into play later, because it means that this is not a "secondary" neoplasm.

Turn to Alphabetic Index for Behavior

Papillary breast cancer is fairly rare, occurring more often in post-menopausal women, so maybe you're not really sure whether the lesion is malignant, benign, or uncertain. That's why you should start your code search in the ICD-10-CM Alphabetic Index to look up the histologic term that the pathologist uses.

Tip: "Carcinoma" and "invasive" are both clues that you're dealing with a malignant neoplasm, but you should always double check the full terminology in the alphabetic index to ensure that you understand the neoplasm's behavior.

Do this: Look up "carcinoma," in the index, and you'll find an indented entry for "papillary, with invasion, specified site -- see Neoplasm, malignant, by site."

Zero In On Code Using Neoplasm Table

Now that you know the tumor's histologic type and behavior, you should turn to the neoplasm table to find the appropriate code. Notice that the alphabetic index directed you to use the neoplasm table "by site," so that means you'll be looking for "breast."

Once you turn to the neoplasm table under "breast," you should look in the column "malignant primary." As noted earlier, the pathology report does not indicate that this is a secondary neoplasm metastatic from another site.

Focus category: As you peruse the appropriate column in the neoplasm table, you'll notice that unless the specimen is breast "skin," the ICD-10 category is C50.- (Malignant neoplasm of breast).

But you can't just report C50. That's a truncated code listing it and would result in a claims denial. You must report the diagnosis code in this case to the sixth digit.

Identify Gender, Location to Finalize Code

If you want to avoid assigning a non-specific ICD-10 code, you need to extract details about this breast case such as the patient's gender, breast laterality, and the specific location of the lesion within the breast. You can't make that stuff up - it has to come from the pathology report. "As always, clinical documentation will be key," says Rhonda Buckholtz, CPC, CPCI, CPMA, CDEO, CRC, CHPSE, COPC, CENTC, CPEDC, CGSC, Vice President of Strategic Development for ECL in Pennsylvania, and, an AAPC instructor and speaker.

The first question you have to answer before you assign the next digit is what "quadrant" is the lesion in?

Problem: Your pathology report uses the description "1 o'clock," for the lesion location, but ICD-10 does not use that terminology. Fortunately, a simple online search will reveal numerous illustrations outlining the specific quadrant for each clock hand. You will see that 1 o'clock correlates to the upper inner quadrant of the right breast, and the upper outer quadrant of the left breast.

That's not all: ICD-10-CM provides distinct codes for male and female breast neoplasm, so you must take that information into account as you select the code.

Bottom line: Given that the pathology report identifies that the lesion is from a female patient's right breast, you should code the case as C50.211 (Malignant neoplasm of upper-inner quadrant of right female breast).