excision of lesion

maxwell@marshall.edu

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have a patient with the pathology findings as follows:

Sections show segments of oral surface stratified squamous epithelium characterized by a moderate disruption in maturation, with atypical rete ridge morphology demonstrating broad and gused forms, disturbed polarity in the deep spinous and basal cell regoins, elevated and often atypical mitotic figures, nuclear hyperchromasia and increased nucleus to cyoplasm ratio. the epithelium is covered with thickened lightly corrugated layers of orthokeratin and parakeratin. segments of this epithelium elicit a dense superficial chronic inflammatory cell infiltrate of lymphocytes associated with significant leykocytic exocytosis. in these regoins, hydropic change is noted in the deep spinous and lasal cell regoins accompanied by numerous cytoid bodies. resident fibrous connective tissue is composed of collagen bundles, ground substance, fibrocystes and small vascular structures.

DX Code submitted to us from pathology: 528.6

the physicians states that this is neither a benign or malignant lesion. Because of the pre- malignant state of the sample he wants to code using the malignant codes

it is my understanding that if it isn't malignant you can't code it as such.

any input would by greatly appreciated.
 

Hopp

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Excision of lesion

I would tend to agree with you. How about using the dx code for
uncertain behavior. Hope this helps! Good Luck
Deb, CPC
 
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