Pathology/Lab Coding Alert
Avoid This ‘Uncertain’ Dx Trap
Question: The pathology report for a urinary bladder specimen simply states “neoplasm” as the diagnosis. Should I code the diagnosis as D41.4? Tennessee Subscriber Answer: No, you should not code the case as D41.4 (Neoplasm of uncertain behavior of bladder).The term “uncertain behavior” is a specific designation about the tumor, just as “benign” and “malignant” are. If the pathology report doesn’t specify that the tissue exam reveals characteristics of “uncertain behavior,” the code is not supported. Instead, the correct code for the case is D49.4 (Neoplasm of unspecified behavior of bladder). Unspecified means just that – the pathologist didn’t specify if the tumor was benign, malignant, or of uncertain behavior. Better: You may ask the pathologist for clarification and then report a more specific code.
Pathology/Lab Coding Alert
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Determine Fluid Specimen Source
Question: Our pathologist evaluated a fluid specimen from an ovarian cyst submitted by an oncologist. [...] - Reader Questions:
Avoid This ‘Uncertain’ Dx Trap
Question: The pathology report for a urinary bladder specimen simply states “neoplasm” as the diagnosis. [...] - Reader Questions:
Bill for Completed Tissue Exam
Question: The surgeon sent five, separately identified colon polyp specimens from a colonoscopy procedure. The [...]
