Wiki Derm Pathology Coding for unspecified DX

[MeganLee]

Coding for a Dermatopathology Lab, often the pathologist will give a diagnosis that is unspecified. Examples: "Characteristic of" "Suggestive of" "Consistent with"

We often use L98.9 but for some reports that are indicating possibility of dx's such as mycosis fungoides and CTCL we feel there should be a better way to code at least from the microexam which usually gives a good description of what the are seeing.

Example:

DX: Characteristic of path-stage mycosis fungoides.

Micro Exam: The basal layer reveals focally marked exocytosis of haloed, medium-sized
lymphocytes. The papillary dermis reveals fibroplasia and a focal band of
small lymphocytes with extravasated red cells. Immunohistochemistry performed
on an accompanying specimen revealed the epidermal lymphocytes are diffusely
CD8-positive.

 

[bbooks]

"Characteristic of" "Suggestive of" and "Consistent with" should be treated differently.

I've never seen a pathologist use "characteristic of," but it seems similar to "consistent with." When a pathologist says a diagnosis is "consistent with" a specified pathology, that diagnosis can be used, unless the pathologist says something to the contrary. For example, sometime the pathologist with say something like "consistent with actinic keratosis." In that case, I would code for actinic keratosis. Sometimes see the pathologist say something like, "Consistent with [diagnosis] in the right clinical setting." With this sort of disclaimer, I would not code for the diagnosis.

"Suggestive of," "suspicious for," and "probable" should not be considered definitive for the diagnosis.

It would be helpful to check with your pathologist to confirm if he/she uses "characteristic of" that he/she is comfortable with your using the diagnosis for coding.

 

[danachock]

coding pathology (inpatient vs outpatient)

Sorry but I need to step in on this post please with both scenarios;

Refer to Section IV for (diagnostic coding and reporting guidelines for outpatient services) Item H in your current ICD-10 book please. It states: Uncertain Diagnosis - Do not code diagnoses documented as "probable" "suspected" "questionable" "rule out" or "working diagnosis" or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, degree of certainty for that encounter/visit/such as symptoms, signs, abnormal test results, or other reasons for the visit.

But if our patient is "inpatient" please refer to Section II item H. please.
Which states: if the diagnosis documented at the time of discharge is qualified as "probable", "suspected", "likely" "questionable" or "still to be ruled out" or other similar terms indicating uncertainty, code the condition as if existed or was established. The bases for these guidelines are the diagnostic workup, arrangement for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.

Is your patient in a "inpatient" or "outpatient" setting??? Then please refer to the provided information to assign proper coding.

Hopefully this clears the mud??

Thanks,
Dana Chock CPC, CANPC, CHONC, CPB, CPMA
Anesthesia, Pathology, Laboratory, Radiology Coder

 

[mitchellde]

the rules for inpatient coding refer only to the facility coder not the prof fee coder. A pro fee coder can never code a diagnosis that is documented as uncertain.

 

[bbooks]

I was assuming that this was a non-facility situation, which is most common for dermatology coding.

MeganLee, I'm curious, did you talk with your pathologist about their use of "characteristic of?"

 

[mitchellde]

I have noticed several of our pathologists using the terminology of "characteristic of". They said it means it looks like but not definitively diagnostic for. therefore I do not code those myself.