Pathology/Lab Coding Alert

Question: Our pathologist recently examined a prostate biopsy specimen for a patient who had been diagnosed with prostate cancer in 2011. The treating physician ordered the biopsy because the patient had been followed with “watchful waiting,” and his PSA level elevated significantly since the initial biopsy. The pathologist did not find cancer in the most recent biopsy. What diagnosis code should we use?

Pennsylvania Subscriber

Answer: You should use the ordering diagnosis — 185 (Malignant neoplasm of prostate) as the ICD-9 code for the prostate biopsy.

Despite the fact that the most recent biopsy procedure evidently missed the tumor, the patient still has cancer, and the physician performed the biopsy to evaluate the cancer. The second biopsy was performed to evaluate the progression of the disease, and you should use the cancer diagnosis as the reason for the test.