Wiki HELP understanding cytology lab report - newbie

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Kelly_Josephine

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I looked online and couldn't find much help as far as reading/interpreting reports. Also had trouble searching this in forums. I am just getting started in coding for ASC... my pre-lab temp code for this was v10.51 with 52000.

I have a lab cytology report that reads:
"Groups of mildly atypical urothelial cells are present, instrumentation effect versus low grade urothelial carcinoma."​

Does "versus" mean that the final clinical dx is the former (benign?) rather than the later (carcinoma)?

Does anyone know of a resource on how to read lab reports for dummies?
 
I would use 236.7 Neoplasm of uncertain behavior of bladder
When the report says "atypical or atypia" I always use uncertain behavior. I never code carcinoma unless it is clearly stated.
Hope this helps :)
 
Agree with 236.7.

"Versus" means that it could be the first diagnosis or it could be the second diagnosis. In this case, it means that the diagnosis is at least as severe as the first, but not sure he/she can quite call is carcinoma. Thus, we code for what is certain.

I'm sorry, I don't know any resources for learning to read pathology reports. Is there someone at your place of work that you can consult with?
 
Cytology

Hi,
I am going to take a big step and assume you are coding a urine sample?
The urinary system is quite large, we are unsure where the "Groups of mildly atypical urothelial cells" really came from.
In my opinion & with this information I would be comfortable applying 238.9.
Thanks,
Dana Chock, CPC, CCA, CANPC, CHONC, CPMA, CPB
Anesthesia, Pathology & Laboratory Coder
 
Dana, thanks for your input. Yes, you raise a good point. We don't know that the atypical cells came specifically from the bladder. At the risk of belaboring the point, might it be possible though to be a bit more specific and use 236.99, Neoplasm of uncertain behavior of other and unspecified urinary organs?
 
236.99

Yes, BBooks - thank you. I agree with you.
Thanks for the more clear/appropriate choice for this pathology.
Dana Chock
 
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