Wiki dx of neoplasm without pathology

[gracigoo]

im having a hard time with the Regulatory and Review department (physician educators) in my company believing its ok to let one of our derm providers use the dx of neoplasm for a biopsy without a path report. ive sent them all kinds of info where it states that a neoplasm has to be classified as either benign, in situ, malignant, or unspecified and that can only be done histologically, so either under a microscope or a pathology report. my provider believes she can look at a lesion and know its a benign neoplasm.
after all my research and everything i sent to them, i have recieved no response from them, and now my supervisor has told me not to contact them any further on this topic because they provided me with all they can.

don't i have the right to refuse to code those charts the provider wants to use the dx of neoplasm without a path report without any reprimand?

 

[hamlinr2005]

My understanding is you cannot code neoplasm until you have a path report.

 

[amymeyers01]

Neoplasm NOS

I haven't had a reason to check the new ICD-10 definition or guidelines on neoplasm NOS, but I do know that you can use unspecified neoplasm if this is the only documentation provided, according to ICD-9. It was part of the section notes under the 239 category.

I am a radiology coder, so we never see the path report and have to go by history and findings in just the rad report to code. I don't think this rule only applies for diagnostic coding. I would check the section notes for unspecified neoplasm.

I hope this helps!
Amy Meyers, CPC

 

[mitchellde]

If you look in the codebook under the D49 heading it states that the term "mass" Is not to be regarded as a neoplasm unless specifically indicated by the provider. Mass in quotes means mass and similar terms such as lump or lesion. Coding clinics stated several years ago that preliminary diagnostic study needs to be performed before an abnormality can be determined to be a neoplasm. If the study is interpreted as a tumor or abnormal growth then you can use neoplasm unspecified. The provider may be coding with the benign or malignant cides, but the coding should be based on the narrative note. In the body of the note does the provider say the lesion is benign or malignant , or does he say it is consistent with a malignancy. Consistent with cannot be coded.
I do not understand why a provider would be so willing to tag a patient with a high risk diagnosis when the path is not a known. I would not code something that has yet to be proven.