Wiki benign tumor vs mass of limb please help!

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ladymatthew

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We had a new patient come into our office for an evaluation of her wrist the physician states "pt has therefore been diagnosed with a most likely benign soft tissue tumor over the ulnar side of the wrist." (he previously ruled out ganglion) would I use dx code R22.31 for lump or mass of the limb or would I search and use D49.89 for neoplasm of unspecified behavior other specified site, since he states it is "most likely benign" ?? any help you can give me would be greatly appreciated. Oh and the pt is also pregnant so I know the complication of pregnancy codes first..... :mad:
 
CodingKing said:
Uncertain behavior can only be determined from a path report as its a specific status. It does not mean i dont know what the status is or benign. I'd go with mass unless there is pathologic evidence of anything else.


I like to point people to the following link that talks about it

http://www.psnextra.org/Columns/CPT-Corner-June-2011.html
Click to expand...

thank you for the information! I was leaning towards that but I thought that "unspecified behavior" was totally different than "uncertain"? I could be totally incorrect and I think I will go with the mass any way for this case.... but for future they are different right?
 
ladymatthew said:
thank you for the information! I was leaning towards that but I thought that "unspecified behavior" was totally different than "uncertain"? I could be totally incorrect and I think I will go with the mass any way for this case.... but for future they are different right?
Click to expand...
If you look Andre catergory D49 in your code book it states:
Note: Category D49 classifies by site neoplasms of unspecified morphology and behavior. The term “mass”, unless otherwise stated, is not to be regarded as a neoplastic growth.
Includes: “growth” NOS
neoplasm NOS
new growth NOS
tumor NOS

Coding clinics have further stated that unspecified behavior is to be used only after a preliminary diagnostic study has been performed and the provider documents it as a tumor, or abnormal growth, or something along that line. We use to call these the "work me up" codes, the provider knows now what the anomaly is not, but does not have information to determine the flavor of neoplasm. He will need to "work it up ". With additional study.
It helps if you remember that these are PATIENT diagnosis codes. If the patient does not definitively have the condition, then you cannot code it.
 
uncertain diagnosis

for inpatient coding if the provider documents a uncertain diagnosis (diagnoses documented at the time of discharge as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out", or other similar terms indicating uncertainty) as if the condition existed or was established.
in outpatient this term is not applicable 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.
in inpatient coding you should code D21.10
if you look into the book neoplasm, soft part or tissue- see connective tissue
under connective tissue -wrist- benign d21.10
 
Coding for uncertainty only applies to the inpatient facility coder, not to the physician treating patients in the inpatient setting. The poster was correct to code this as a mass and not as a benign neoplasm since she indicated she was coding for the physician encounter.
 
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