Wiki Patient "Assessment" question

[TLC]

When one of our doctors removes a lesion that they "FEEL" is going to be Squamous,Basal Cell is it ok to put that diagnosis down in the "assessment"? Or should it be coded 238.2. Unspecfied. When they code it as malig then it turns out to just be AK or SK, the patient chart has a wrong diagnosis in it. We wait to actually bill out for the service until the path comes back so it gets sent to the insurance company correct. So does the assessment make much difference since the path will prove what the lesion was?. Sorry if this was confusing wasn't sure how to say what I wanted. Thank you

 

[danachock]

coding "feel"

Hi, I have my CHONC study guide dated 2013 in hand. It states "do not code a diagnosis documented as probable, suspected, questionable, rule out, or working diagnosis, or any similar term indicating uncertainty." Rather, code the conditions to the highest degree of certainty for that encounter or visit.

This is a great coding example that was provided in the study guide:
The patient has a probable basal cell carcinoma on the right chest. The lesion was biopsied. The specimen has been sent to the lab, but the results are not back. The best practice is to wait for the pathology results. If the claim is submitted prior to receiving the pathology report, code for the lesion, which is reported with 709.9. It is unclear if the "lesion" is a neoplasm. However, many physicians use the term lesion when they mean neoplasm in integumentary diagnoses. If this is the case with your physician, get it in writing in your policies and procedures, and code 239.2 Unspecified neoplasm of bone, soft tissue, or skin. Never select a code for uncertain behavior or report the lesion as basal cell carcinoma. Always code to the most specific information provided.
Thanks,
Dana Chock, CPC, CCA, CANPC, CHONC
Anesthesia, Pathology, and Laboratory Coder