Pathology/Lab Coding Alert

Question: Our pathologist diagnosed a normal colon biopsy that the physician ordered to rule out tropical sprue. What diagnosis code should we use since the biopsy was normal?

Ohio Subscriber

Answer: Youll have to report the ICD-9 code for signs, symptoms, or conditions that the ordering physician provided with the biopsy. That may be a symptom such as diarrhea (787.91, Diarrhea) or a condition such as nonspecific intestinal malabsorption (579.9, Unspecified intestinal malabsorption).

ICD-9 coding guidelines instruct that you should not code a rule out as if it is the actual diagnosis (except for hospital inpatients). That means you should not report the ICD-9 code for sprue (579.1, Tropical sprue) since the findings did not document that condition.