Wiki Surgical path report does not indicate which dysplasia

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cubbiecatz

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Our Leep and Colposcopy path reports always came back noted with mild, moderate, severe or CIN I, II or III.

I have now received this surgical path report:
A. Cervix, LEEP:
-Low grade to focally high-grade squamous intraepithelial lesion (LSIL–HSIL), endocervical margin negative.

B. Endocervix, curettage:
-Fragments of endocervical mucosa, negative for dysplasia.
Immunohistochemistry Stains --
Specimen A: Immunostain p16 has patchy positivity in areas of dysplasia. Positive and negative controls stained appropriately.

Would I use the unspecified dysplasia diagnosis or do I continue to use the diagnosis from the PAP:
Source:
Cervical/Endocervical,
ThinPrep Pap Test w/o Imager
Cytology Diagnosis:
HIGH GRADE SQUAMOUS INTRAEPITHELIAL LESION
Specimen Adequacies:
Satisfactory for evaluation.
Endocervical and/or squamous metaplastic cells (endocervical component) are present.
The pap smear is a screening test with limited sensitivity and false negative test results can occur.


Thank you, Cathy
 
cubbiecatz said:
Our Leep and Colposcopy path reports always came back noted with mild, moderate, severe or CIN I, II or III.

I have now received this surgical path report:
A. Cervix, LEEP:
-Low grade to focally high-grade squamous intraepithelial lesion (LSIL–HSIL), endocervical margin negative.

B. Endocervix, curettage:
-Fragments of endocervical mucosa, negative for dysplasia.
Immunohistochemistry Stains --
Specimen A: Immunostain p16 has patchy positivity in areas of dysplasia. Positive and negative controls stained appropriately.

Would I use the unspecified dysplasia diagnosis or do I continue to use the diagnosis from the PAP:
Source:
Cervical/Endocervical,
ThinPrep Pap Test w/o Imager
Cytology Diagnosis:
HIGH GRADE SQUAMOUS INTRAEPITHELIAL LESION
Specimen Adequacies:
Satisfactory for evaluation.
Endocervical and/or squamous metaplastic cells (endocervical component) are present.
The pap smear is a screening test with limited sensitivity and false negative test results can occur.


Thank you, Cathy
Click to expand...

The ICD-10 code for high-grade squamous intraepithelial lesion (HSIL) confirmed by biopsy of the exocervix is D06.1, which is used for cervical intraepithelial neoplasia grade 3 (CIN III). You can report this code because the biopsy found both low and high grade lesions on the exocervix. You can also report N87.0 since low grade lesions were also found on the exocervix and represent CIN I.
 
nielynco said:
The ICD-10 code for high-grade squamous intraepithelial lesion (HSIL) confirmed by biopsy of the exocervix is D06.1, which is used for cervical intraepithelial neoplasia grade 3 (CIN III). You can report this code because the biopsy found both low and high grade lesions on the exocervix. You can also report N87.0 since low grade lesions were also found on the exocervix and represent CIN I.
Click to expand...
Thank you Melanie!

Do we know it's the exocervix because the endocervix margin is negative?
 
Hello cubbiecatz and nielynco
I would like to comment on this post please.

Specimen A
Low grade to focally high grade squamous intraepithelial lesion (LSIL-HSIL), endocervical margin negative. Well, this was anything but a pap smear, warranting 88307x1

Why are you referring to the Pap here? You already have the information to code both Specimen A and B. R87.613 from a pap smear is from cytological findings. This is clearly not cytological here; but wholeheartedly surgical findings.

Specimen B
Endocervix, curettage with nothing to report. Billed with 88305x1

I’m completely confused on why the exocervix is the diagnosis code here. Because the LEEP removed included both the endocervix and the exocervix and just because they stated the endocervix margins were negative doesn’t mean that HSIL was designated in the Exocervix here. This is clearly anything but cut and dry here. Just so you know; the pathologists are responsible for checking the margins (similar to breast specimens for cancer). They are telling the surgeon, that the margin is negative and no more cervix needs to be removed currently to obtain “clean margins”. The pathologist from the pathology report simply did not define exactly where it was located here. No way would I have used D06.1 here.
Multifactor. You are going to give a patient carcinoma in situ of a location that isn’t confirmed that probably warranted moderate dysplasia N87.1 and this is going on their medical record moving forward.
Pathology coders are absolutely not clinicians, we code what we have in our pathology report and to make that assumption is not correct coding practice.
Why does anyone assume HSIL is automatically D06.x? High grade SIL falls into the Moderate Dysplasia (N87.1) and Severe Dysplasia buckets (D06.x) for diagnosis assignment.
If you provide me solid resources to tell me otherwise, I will review them. It just seems like a few assumptions here and I am trying to assist with correct pathology coding.
Thank you for allowing my response and I look forward to chatting soon.
Dana
 
danachock said:
Hello cubbiecatz and nielynco
I would like to comment on this post please.

Specimen A
Low grade to focally high grade squamous intraepithelial lesion (LSIL-HSIL), endocervical margin negative. Well, this was anything but a pap smear, warranting 88307x1

Why are you referring to the Pap here? You already have the information to code both Specimen A and B. R87.613 from a pap smear is from cytological findings. This is clearly not cytological here; but wholeheartedly surgical findings.

Specimen B
Endocervix, curettage with nothing to report. Billed with 88305x1

I’m completely confused on why the exocervix is the diagnosis code here. Because the LEEP removed included both the endocervix and the exocervix and just because they stated the endocervix margins were negative doesn’t mean that HSIL was designated in the Exocervix here. This is clearly anything but cut and dry here. Just so you know; the pathologists are responsible for checking the margins (similar to breast specimens for cancer). They are telling the surgeon, that the margin is negative and no more cervix needs to be removed currently to obtain “clean margins”. The pathologist from the pathology report simply did not define exactly where it was located here. No way would I have used D06.1 here.
Multifactor. You are going to give a patient carcinoma in situ of a location that isn’t confirmed that probably warranted moderate dysplasia N87.1 and this is going on their medical record moving forward.
Pathology coders are absolutely not clinicians, we code what we have in our pathology report and to make that assumption is not correct coding practice.
Why does anyone assume HSIL is automatically D06.x? High grade SIL falls into the Moderate Dysplasia (N87.1) and Severe Dysplasia buckets (D06.x) for diagnosis assignment.
If you provide me solid resources to tell me otherwise, I will review them. It just seems like a few assumptions here and I am trying to assist with correct pathology coding.
Thank you for allowing my response and I look forward to chatting soon.
Dana
Click to expand...
Hi Dana, this isn't for any of the pathology coding. It is for the physician for the surgical procedure. The PAP was mentioned by me, because if you look at it again, I was asking if I could code from that path report as it didn't have the same wording that is usually on them, or if I needed to stick with the diagnosis for the reason the Colpo was performed. I came here with my question for clarification.
We code the highest level when it encompasses two ranges. That is how my physicians diagnose the Colpo.
"High-grade squamous intraepithelial lesion (HSIL) encompasses the conditions previously termed cervical intraepithelial neoplasia grades 2 and 3 (CIN 2 and CIN 3), moderate and severe dysplasia, and carcinoma in situ" from https://www.ncbi.nlm.nih.gov/sites/books/NBK430728/
 
cubbiecatz, @nielynco

-Low grade to focally high-grade squamous intraepithelial lesion (LSIL–HSIL) that I captured from your original post. Please tell me how we get to carcinoma in situ here? I have my documentation; please show me yours. I am not sharing mine until I see yours,
Yes, there were ranges but to assume HSIL is deemed to deserve D06.x (carcinoma in situ here) is absolutely not accurate. Again, I will stand on my little hill and protect the pathology integrity of coding all day long.
If your facility codes to highest level of specificity, you may be giving In Situ Neoplasm codes when it just simply doesn’t exist, not my problem, it is yours. You stand alone on that hill and state what you know, put your hand on whatever when you enter the judge’s box here for integration.
I am confident with rationale, what diagnosis codes are appropriate.
You ask your pathologists about HPV, LGIS, HGIS along with CIN here (they will have a long story for you.) They are all so super sweet like the documents they gave me.
I don't need to review your link. I already know when HGIS is billable and why.
Have a fantastic evening,
I will utilize the documents I have to derive the accurate coding assignment until I am told I am wrong here.
Dana
 
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