Part B Insider (Multispecialty) Coding Alert

Neoplasm Coding:

3 FAQs Help You Hone Your Uncertain vs. Unspecified Diagnoses

Published on Mon Mar 16, 2015

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Hold claims for pathology report when possible.

You may not always be able to narrow down your diagnoses to a definitive code, which means you could have to turn to “uncertain” or “unspecified” codes. Make sure you aren’t missing a more specific diagnosis code and keep proper documentation in your defense.

Check out the answers to these three frequently asked “uncertain” vs. “unspecified” questions, and keep your neoplasm diagnoses straight.

Question 1: How can we determine when to submit the “uncertain” codes?

Answer: Using 238.2 (Neoplasm of uncertain behavior of skin) and 239.2 (Neoplasm of unspecified nature of bone, soft tissue, and skin) are familiar choices in oncology diagnoses. It’s not unusual that you would substitute one for the other, since both codes refer to a lesion that is not certain in nature. However, if you look closely at their definitions, you’ll find a very distinct difference.

“Uncertain” is used when the pathology report contains words such as “dysplastic,” “atypical,” or “unusual.” In addition, there are some neoplasms that may have a slight chance of becoming malignant at some date, such as congenital nevi or junctional nevi. “Using ‘uncertain’ means there is supporting documentation the cells have been confirmed by a pathologist to have a specific characteristic,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Director of Reimbursement and Advisory Services, Altegra Health, Inc.

Question 2: When should you report an “unspecified” code?

Answer: When the pathology report doesn’t confirm a specific type of neoplasm — benign, malignant, or uncertain — you should report an unspecified code.

For instance: You’d use an unspecified code if you’re billing before you have the biopsy results or when the pathology report does not contain enough information to select a more specific code. “Unspecified” indicates the provider did not reach a specific diagnosis or may still be waiting on the pathology to determine the type of cell present.

Coverage alert: Most payers have policies that provide lists of covered diagnoses. Many of these medical necessity policies include codes from category 238 but not from category 239. Do not be tempted to use a 238 code to satisfy the coverage requirement for payment unless you have supporting documentation that the cell type can be appropriately identified as “uncertain.”

Difference: Code 239.2 is a broader descriptor as it could describe a lesion of bone, soft tissue, or skin, whereas 238.2 is limited to skin lesions. It [239.2] also describes a lesion that has not been pathologically diagnosed, notes Pamela Biffle, CPC, CPC-P, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Austin, Texas. In these cases, no biopsy has been performed so no definitive diagnosis is available.

Question 3: How should you find the right diagnosis?

Answer: You should not use an uncertain or unspecified code when you — the coder — are uncertain, say experts. Don’t simply flip to the neoplasm table and select a code from either of these columns.

Do this: Instead, you should use the alphabetic index to look up the name of the tumor or available diagnostic information. The index directs you to the appropriate column in the neoplasm table. 

For example, if you look up “tumor” in the ICD-9-CM alphabetic index, it states, “see also: neoplasm, by site, unspecified nature.” Before assigning a final code, verify the diagnosis you have selected in the tabular index. The tabular list provides additional information that you won’t find in the alphabetic listing or neoplasm table. 

A specific category might show a list of terms that the code “includes” or “excludes.” Here you may find a term that you see in the pathology report, which helps you confirm an accurate diagnosis or avoid a wrong one.

Tip: “Includes” lists aren’t exhaustive, so if a term in the index directs you to a code, that’s the correct code even if the term is not in the inclusion list.