Wiki Need help w/ Dx code off of path report! Please:)

[emilyadams1993@yahoo.com]

Clinical History ---
Bladder cancer. Medical History: Gross hematuria. Urinary frequency.
Dysuria. Urinary retention with incomplete bladder emptying. Coronary
artery disease. Lower urinary tract infection. Back pain. Arthritis.
Smoking.




---Final Pathologic Diagnosis---

A. Left bladder wall, lesion, transurethral resection:
- Nephrogenic metaplasia, prominent von Brunn's nests and chronic
inflammation
- Muscularis propria is not identified


Comment: Immunohistochemical stains performed on block A1 for PAX8
(positive), AMACR (positive), p63 (negative), and HMWK (negative) support
the diagnosis.



what Dx code would you give this?

 

[emcee101]

I would code only the chronic inflammation, 595.2 or 595.9. The other pathological symptoms - von Brunn's nests and nephrogenic metaplasia, are symptoms of cystitis or another possible diagnosis. I would defer to the provider who performed the biopsy for any additional diagnosis based on their clinical knowledge, as it would be out of a coder's scope of work and knowledge to code anything futher, in my opinion.

Side note: I have never seen the nephrogenic metaplasia on a bladder path report before so I looked into it a little. Here is one interesting webpage that I found.

http://www.pathologyoutlines.com/topic/bladdernephroadenoma.html

Hope this helps