Urology Coding Alert

Read the documentation and put your diagnosis coding skills to the test

Now that you’re up-to-speed on choosing an ICD-9 Code from the physician’s notes, read the following sample documentation and determine whether you can put the correct diagnosis code on your physician’s claim form:

Documentation: “Examination of the scrotum revealed a 9-mm lesion on the anterior right scrotal sac. I surgically excised the lesion. The lesion had a red outer crust and an irregular border, but I am uncertain of the lesion’s status. Sent lesion to the lab and will await results.”


How did you fare? Most coders tell us that they would assign 236.6 (Neoplasm of uncertain behavior of genitourinary organs; other and unspecified male genital organs) to this claim. But this is actually the wrong code for this physician’s documentation.

You can only report 236.6 if the pathologist who examines the sample states that the lesion exhibits uncertain behavior. The pathologist must make the diagnosis from the histopathology.

In fact, according to ICD-9, “uncertain behavior” means something totally different than what people think, says Chris Felthauser, CPC, CPC-H, ACS-OH, ACS-OR, PMCC, medical coding instructor for Orion Medical Services in Eugene, Ore.

For example: “Sometimes a physician will review a patient’s lesion that is growing in size, or changing color or irritating a patient, and from looking at the lesion it is ‘uncertain’ to the physician whether or not this lesion is benign or malignant, so he elects to remove it and send it to path for review,” Felthauser says. If, as in the above case, the lesion has not yet been histologically assessed, you should not report 236.6

You should either wait for the pathology report to determine the correct ICD-9 code, report a diagnosis code based on the symptoms alone, or select an “unspecified” code such as 239.5 (Neoplasms of unspecified nature; other genitourinary organs).

Tip: “If the lesion was irritated, bleeding or had other such features, make sure you have that information documented as well because most carriers do not cover ‘cosmetic’ removals of benign skin neoplasms,” Felthauser says. “So you need to make sure there is documentation as to why he chose to remove it and remember to code for those services.”

Secondary diagnoses that may be required for payment of the above-named lesions include 459.0 (Hemorrhage, unspecified) and 608.4 (Other inflammatory disorders of male genital organs).