Pathology/Lab Coding Alert

Question: The pathologist examines a lumpectomy specimen in which the op note states that the patient has a history of DCIS. We don’t have the final diagnosis before submitting the bill. How should I code the diagnosis?

Arkansas Subscriber

Answer: Ideally, you would wait for the pathology report and code the final diagnosis for the lumpectomy.

Without a final diagnosis, you’ll have to code the “ordering diagnosis” or the reason for the test. You don’t mention any other signs or symptoms from the op report, such as a perceived “lump” or an abnormal mammogram. With the information you have, you’re left with coding the personal history of ductal carcinoma in situ (DCIS).

The appropriate ICD-10 code would be Z86.000 (Personal history of in-situ neoplasm of breast).

Don’t confuse the personal history code with codes for the condition, which are:

• D05.10 (Intraductal carcinoma in situ of unspecified breast)
• D05.11 (Intraductal carcinoma in situ of right breast)
• D05.12 (Intraductal carcinoma in situ of left breast).