Wiki Coding Uncertain diagnosis

[JesseL]

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.

Thanks

 

[mitchellde]

You will never use 238.2 without a path report. The only code you can use is one that will fit the symptoms for the reason for the encounter. 238.2 is not a diagnosis for provider uncertainty, it is a dx rendered by a pathologist after an examination of tissue or fluid under a microscope.