Urology Coding Alert

Question: One of our physicians saw a Medicare patient and on examination suspects that he has prostate cancer. The patient refused a prostate biopsy. The physician wants to start the patient on Eligard/Firmagon injections. Can we use the diagnosis of prostate cancer to support the need for injections even though the cancer has not been confirmed by biopsy?

Florida Subscriber

Answer: According to ICD-10 coding guidelines, facilities can only code uncertain diagnoses for inpatient claims; an individual physician or outpatient facility cannot code in this manner. The guidelines state, “Do not code diagnoses documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ or ‘working diagnosis’ or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.”  

If the urologist documented that he “thinks” the patient has prostate cancer, that is an indication of uncertainty and shows that the physician is using prostate cancer as a working diagnosis rather than a confirmed diagnosis. This does not support coding a prostate cancer.

If, however, the urologist based on his full examination of the patient documents that the patient has clinical evidence of prostate cancer, and his final “clinical diagnosis” is prostatic carcinoma C61 (Malignant neoplasm of prostate), then there is reason to proceed with the injections even though the diagnosis has not been confirmed with a prostate biopsy and pathology report.

A diagnosis of a malignancy carries certain implications and can affect other diagnoses or treatments in the future. However, your urologist’s clinical diagnosis is sufficient in the above case to initiate treatment based on clinical findings. You will want to be correct in your code assignment, so you will need clear clinical verification and documentation of the diagnosis before listing it.