Wiki Uncertain vs. Unspecified Neoplasm

[melwalters]

I have to code a polyp that was removed and I don't have the path report yet. Should I use a code from the "uncertain behavior" category or "unspecified" category? I know that waiting for the path report is best in order to code to the highest specificity but my doc wants to get the claim out.

 

[mitchellde]

you cannot use 238.x codes for uncertain behavior without a path report. The use of the 239.x codes for unspecified is for when a preliminary diagnostic study documents this is a tumor, or growth, 239.x codes are to be used when there is further work up to be done to determine the specific pathology. You can code as a polyp or wait for path.

 

[juliedurfee]

Polyp without Path

As one who codes the path reports, you should use 239.0 (unspecified gastrointestinal tract) and/or code the presenting symptoms (rectal bleed 569.3, diarrhea 787.91, personal history of polyps V12.72) or whatever your patient's presenting symptoms warranting the polypectomy are. At least that's what I do.

 

[HDaniels]

"uncertain behavior" is to be used when the PATHOLOGY REPORT states there is precancerous cells. A code from "unspecified" is appropriate when there is no pathology report. You didn't state where the polyp is, so I couldn't suggest a code, but I am sure of the ucertain vs unspec.
I recently finished the AAPC prep course for the CPC and that was one of the things I wanted to be very sure of so I noted it in my code book

 

[mitchellde]

Coding clinics and the CDC state that unspecified (239.x or D49.x) Is to be used after a preliminary diagnostic workup specifies the diagnosis as a "tumor" or a "growth" If you have a dx of a polyp then that is what you should code, look up the term polyp and then location. if it is a rectal polyp then code for that if it is an intestinal polyp then code that, you do not have the documentation for an unspecified neoplasm and you do not have a path report for uncertain behavior