LaurieEaston
Contributor
Greetings ~
Hoping for a discussion/explanation of how you handle ICD-10 coding for the pathologist in your laboratory when a specimen fails to yield a definitive diagnosis.
The official ICD 10 guidelines in Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services instructs us that in the absence of a definitive diagnosis we are to report the symptom as the diagnosis. For a pathology lab, this would be the referring physician's clinical diagnosis.
I am trying to reconcile this when the referring clinician submits a specimen for a stated malignancy which is not seen by the pathologist in the specimen and is reported out (by the pathologist) without a definitive diagnosis.
Here is a simple (redacted) example:
TISSUE/SPECIMEN: 1. Voided urine
DIAGNOSIS:
Voided urine (concentration preparation):
Satisfactory for evaluation.
Negative for High Grade Urothelial Carcinoma.
CLINICAL INFORMATION:
Transitional cell carcinoma of bladder
If I am to understand the Official ICD-10 Guidelines and advice from APF Pathology Service Coding Handbook, this case would be coded with C67.9 - Malignant neoplasm of bladder, unspecified. However, I am conflicted because that is not representing the results as reported by the pathologist (it could even be argued that this choice of ICD 10 is contradictory to the pathology findings).
It has been brought up that a personal history code could be used, (Z85.51 - Personal history of malignant neoplasm of bladder), but it's very possible that this is not accurate either AND it also poses the question about using a personal history ICD 10 as a primary code (can we also discuss this? lol! maybe not in this thread?).
I am curious, Fellow Pathology Coders - how do you handle coding these kind of scenarios?
Thanks in advance for the discussion!
Hoping for a discussion/explanation of how you handle ICD-10 coding for the pathologist in your laboratory when a specimen fails to yield a definitive diagnosis.
The official ICD 10 guidelines in Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services instructs us that in the absence of a definitive diagnosis we are to report the symptom as the diagnosis. For a pathology lab, this would be the referring physician's clinical diagnosis.
I am trying to reconcile this when the referring clinician submits a specimen for a stated malignancy which is not seen by the pathologist in the specimen and is reported out (by the pathologist) without a definitive diagnosis.
Here is a simple (redacted) example:
TISSUE/SPECIMEN: 1. Voided urine
DIAGNOSIS:
Voided urine (concentration preparation):
Satisfactory for evaluation.
Negative for High Grade Urothelial Carcinoma.
CLINICAL INFORMATION:
Transitional cell carcinoma of bladder
If I am to understand the Official ICD-10 Guidelines and advice from APF Pathology Service Coding Handbook, this case would be coded with C67.9 - Malignant neoplasm of bladder, unspecified. However, I am conflicted because that is not representing the results as reported by the pathologist (it could even be argued that this choice of ICD 10 is contradictory to the pathology findings).
It has been brought up that a personal history code could be used, (Z85.51 - Personal history of malignant neoplasm of bladder), but it's very possible that this is not accurate either AND it also poses the question about using a personal history ICD 10 as a primary code (can we also discuss this? lol! maybe not in this thread?).
I am curious, Fellow Pathology Coders - how do you handle coding these kind of scenarios?
Thanks in advance for the discussion!