Wiki Diagnosis coding for neoplasms that aren't biopsied

[nbuck]

Hi there,
I work in a family practice office and recently had a case occur where the doctor looked at a "mole" and determined it to be a benign neoplasm by its appearance. For diagnosis coding, since the physician is certain it's benign, would you use the benign neoplasm code? Or since there wasn't a pathology report to confirm it was benign, would you use the neoplasm of uncertain behavior code?

Thanks in advance!

 

[bwolfe1]

If the "mole" was located on the skin, look at "Nevus, Skin" codes, D22X, and then further query the MD if he prefers the benign neoplasm code and then code by location, D23X.

 

[mitchellde]

To be benign or uncertain n behavior or malignant, there must be a histologic interpretation provided after exam under a microscope.

 

[CodingKing]

uncertain behavior does not mean "I don't have a pathology report" or "I did not send for pathology". Here is a good link explaining what Uncertain Behavior is

http://www.psnextra.org/Columns/CPT-Corner-June-2011.html