Wiki Neoplasm coding

[Lynda Wetter]

I remember being told we cannot code a malignancy without final pathology.
For example Physician sees a patient for a lesion on the leg and referrs to dermatology for what he says looks like malignancy. That provider cannot code malignant. Where can I find that in the ICD guidelines. Or would that fall under not coding possible, rule out suspcted dx's?

 

[teresabug]

If the dr's documentation states "probable" "possible" "rule out" you cannot use that code. I have always held the claim until the path report comes back.
Hope this helps!

Teresa

 

[Dhaneshmurali]

Uncertain Diagnosis

Hi,


Yes. You can't code qualified conditions (?probable?, ?suspected?, ?likely?, ?questionable?, ?possible") until confirmed by provider.

In ICD-9-CM, section-II (selection of principle guidelines) part having guidelines for qualified conditions below the title of Uncertain Diagnosis.



Regards,

Dhanesh M

 

[AnnaE]

neoplasm coding

If the report states "consistent with" ependymoma- can this be coded as a definitive diagnosis?

Thanks

 

[danachock]

"Consistent with"

If the pathology report states "consistent with" ependymoma - that is not codeable. Was anything else stated in the pathology report?
Thanks,
Dana Chock, CPC, CCA, CANPC, CHONC, CPMA, CPB
Anesthesia, Pathology & Laboratory coder