Actinic Keratosis without Path Report?!

anne32

Networker
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98
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If I understand correctly, we cannot code a lesion as benign or malignant until it comes back from pathology...but I have a chart where the provider says the lesion looks like AK and cauterized the lesion. Can this be coded as AK without confirmation from a path report? If I'm correct, then what dx would I use??
 

mitchellde

True Blue
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13,537
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Columbia, MO
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Saying that a lesion looks like an Actinic keratosis is considered an uncertain diagnosis. You cannot code uncertainty for physician coding. You go to lesion then skin and you get L98.9 this is the diagnosis you can use without a path report.
 
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