Does Uncertain Behavior Mean the Same as Unspecified?
Question: I have an encounter note from a visit with a 50-year-old patient who presented with persistent cough, chest pain, and unexplained weight loss. The pulmonologist performed a bronchoscopy with a bronchial biopsy of a tumor in the right bronchus. The pathology results of the biopsy showed abnormalities, but the laboratory was unable to confirm if the sample was benign or malignant. The sample was sent to an oncologist for further evaluation. What codes will I report? Kansas Subscriber Answer: Use 31625 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial or endobronchial biopsy(s), single or multiple sites) to report the bronchoscopy with biopsy of the tumor in the right bronchus. You’ll assign D38.1 (Neoplasm of uncertain behavior of trachea, bronchus and lung) to report the tumor in the right bronchus. The pulmonologist confirmed the presence of a tumor in the documentation during the bronchoscopy. Uncertain behavior is indicative that pathological testing has been performed on the specimen, but the sample has not been confirmed as malignant or benign. At the same time, you shouldn’t use uncertain behavior as an unspecified designation. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
