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Question: A patient presented to a provider’s office with a painless lump behind their ear. The 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 I code the diagnosis?

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Answer: In this case, you should report the diagnosis as R22.1 (Localized swelling, mass and lump, neck) and not as a confirmed diagnosis of pilomatrixoma coded to D23.4 (Other benign neoplasm of skin of scalp and neck).

Here’s why: For outpatient services, ICD-10-CM Official Guidelines, Section IV.H, 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.”

Pathology reports should not include those terms when stating a final, definitive diagnosis, but pathologists sometimes include the terminology. When they do, you should assign a code based on the symptoms listed in the report, which would lead you to report R22.1, not D23.4.

Alternatively, you may want to consult your pathologist for clarification, possibly initiating a discussion about how documentation using those terms can negatively impact coding and, consequently, treatment and billing.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC