Wiki "Consistent With" Dx

[MI_CODER]

Hello, what would you code for the diagnosis? The op report uses phrases such as "consistent with" and "likely" while the path report uses the phrase "suggestive of". I'm an outpatient coder so I'm thinking the only diagnosis I can use is R22.31. However, I thought I heard we could use a suggestive of diagnosis if it's in the path report. I'm not sure where I heard that or if that's correct? Any help is appreciated! Thanks in advance.

Post-operative Diagnosis: Mass of right wrist [R22.31]

Specimens: likely inclusion cyst

A small oblique incision was made over the mass which was in line with the previous scar blunt dissection revealed the mass which was deep in the subcutaneous tissue we dissected free any branches of the superficial radial nerve from it. It excising the mass from the surrounding scar it did burst expressing material that appeared to be consistent with an inclusion cyst. We resected the mass we thoroughly irrigated the wound looking for any remnants we will send it to pathology as she has a history of squamous in the area but it did not appear consistent with a mass that would be consistent with squamous cell carcinoma. The wound is irrigated again and closed with a 4-0 nylon.

PATHOLOGICAL DIAGNOSIS:
A. Mass right wrist, excision: Foreign body giant cell reaction with associated keratin debris,
suggestive of ruptured epidermal inclusion cyst.

 

[nsteinhauser]

From the ICD-10 guidelines a couple years ago:
The FY2020 ICD-10 guidelines, which went into effect October 1, included the addition of “compatible with” or “consistent with” to terminology that cannot be used to indicate uncertain diagnosis for outpatient services. In the guidelines, CMS states the following: “Do not code diagnosis documented probable, suspected, questionable, rule out, compatible with, consistent with, or working diagnosis or similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for the encounter or visit, such as symptoms, signs, abnormal test results or other reason for the visit.”
It is common now to see 'consistent with' and 'suggestive of' and 'compatible with' on a lot of pathology reports, more now than years ago, it seems. Unfortunately, that isn't something you can code. You'll have to use the most CERTAIN thing you have and it sounds like that is the R22.31. It makes me want to send flowers to the Pathologists who actually state a definitive diagnosis in a path report. I know they have protocols they have to follow but reading path reports all day that say 'suggestive of' makes me wonder why we ever look at all.
Hope this helps.

 

[MI_CODER]

Thank you! That makes sense and what I was thinking. I appreciate you taking the time in providing such a detailed explanation.