Pathology/Lab Coding Alert

Question: The pathology report documents dysplasia of prostate. How should we report the diagnosis under ICD-10? Is dysplasia considered a primary neoplasm of prostate?

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Answer: For this case, without an indication of the severity of the dysplasia, you should report N42.3 (Dysplasia of prostate). Yes, dysplasia is a primary neoplasm of prostate.

When your pathologist documents dysplasia, ICD-10-CM directs you to “neoplasia, intraepithelial, prostate.” The appropriate ICD-10-CM codes depend on the documented severity.

What is dysplasia? Dysplasia is an erroneous development in cells at an early stage in cancer. There may be a proliferation of cells of abnormal morphology and function.

Carcinoma in situ implies that the abnormal cells remain confined to where they originated and do not spread to deeper or adjacent tissues. When the cancer cells are confined within the epithelium where they originated, it is called primary intraepithelial neoplasm (PIN). Depending upon the depth and extent of spread of the abnormal cells, PIN can be of grade I, II, and III.

PIN Codes: If your pathologist documents PIN III, you should use D07.5 (Carcinoma in situ of prostate). If your pathologist documents PIN I, PIN II or does not specify severity, you should use N42.3 (Dysplasia of prostate).