Primary Care Coding Alert

Question: The pathology report mentions dysplastic nevus. Is there an ICD-9 code for this?

New Mexico Subscriber

Answer: A dysplastic nevus, which is also known as an atypical mole or Clark's nevus, is considered a benign neoplasm. ICD-9 classifies benign neoplasms of the skin via anatomic location (216.x), therefore, you should code to the specific site. For example, if it appears on the shoulder, then code it as:

• 216.6 -- Benign neoplasm of skin of upper limb including shoulder.

When coding for neoplasms, the most important document you should utilize is the histopathology report, which basically is the official result from the biopsy performed. You should be able to distinguish between benign or malignant neoplasms from the report. Unfortunately, the medical terms mentioned in the histopathology report are oftentimes not seen in the ICD-9 manual; for example, a biopsy done on skin lesions of the chest is reported as "mild dysplastic compound nevus, margins free." Moreover, it is sometimes not specified whether these lesions are benign or malignant. To avoid errors, it is also helpful to have a basic understanding of medical terminology aside from the experience in coding.

Dysplastic nevus represents a greatly increased risk for melanoma (a form of malignant skin cancer). In patients where a family history of melanoma is known (for example, confirmed cases of melanoma in one or more first- or second-degree relatives), physicians may order a biopsy for dermal lesions to screen for malignancy. In this instance, the more appropriate code will be:

• V16.8 -- Family history of malignant neoplasm; other specified malignant neoplasm.