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Otolaryngology Coding Alert

Reader Question:

Don't Go Beyond What The Procedure Describes

Published on Fri Sep 09, 2011

Question: A patient came in for biopsy of a mandibular cyst, but the doctor didn't find anything. What diagnosis code(s) should I use?Nevada SubscriberAnswer: Don't bill a cyst code if the physician didn't find a cyst doing the procedure. The biopsy may be "nothing" meaning it came back benign. Remember, the procedure note will determine the appropriate codes.Nevertheless, some possibilities include using an abnormal radiological findings ICD-9 code like 793.0 (Nonspecific (abnormal) findings on radiological and other examination of skull and head) -- that is, if something abnormal was seen on an xray. You can use 784.99 (Other symptoms involving head and neck) for the reason you performed the biopsy. You can also code V71.89 (Observation for other specified suspected conditions).
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