Wiki Coding Uncertain diagnosis

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JesseL

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Dr thinks the patient has hemorrhoids but is unsure if that's what it really is so the patient was referred to a GI.

Would I code 239.2 neoplasm uncertain nature or hemorrhoids?

This is for dermatology office visit.
 
i only have flappy papule to work with at the moment. would i use 709.8? other specified disorder of skin
 
If it is a skin condition then yes, if it is in the anal area you might need a GI code it is a little hard to say given the symptom of flappy papule. Is there any additional information, such as the reason for the encounter, was there pain or bleeding.
 
Just that it's bigger and irritated and it's in the anus. I'm thinking of going 235.5, neoplasm of uncertain behavior, anus?

Neoplasm of unspecified nature
Skin flap-like papule located on inferior aspect of anus
Medical Decision Making: Neoplasm of unspecified nature , observe
POC: Recommendation is Explained that it might be hemorrhoids, thus is it best for patient to seek consult from a GI for evaluation. Explained that it may be possible for the growth to get bigger, but it is stepping over our realm of specialty to biopsy a growth on the anus.
 
No you cannot use 239 either read in your code book it states a "mass" ( meaning mass and similar terms like papule) is not to be regarded as a neoplasticism growth. You need the provider to have a preliminary diagnostic report such as a scan when the dx is rendered as an abnormal growth or tumor.
 
The provider didn't do anything but referred the patient to a GI so there's no way I can get a definite diagnosis from the provider.. I don't see what other code I could use other than 235.5, because the provider doesn't know what it is..
 
I would go with 569.49, look in the alpha under papillitis, rectum. You cannot call it dysplasia because the provider does not have that result. The ICD-9 CM codes are patient diagnosis codes, you cannot use uncertain behavior just because the provider does not know what the patient has, because the codes are not created for the purpose of the physician's thoughts. He states anal papillae so that is where I would go.
 
You don't code: Rule Out, Possible, or Unknown Dxs. Only those that you know. Even if is very general in nature. Example: Shortness of Breath, Rule Out COPD. You'd code the SoB not the COPD.
 
I tend to agree with Debra
569.49 (Irritation, anus)

Dr. JesseL documentation states '- irritated and it's in the anus - '
 
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