There's no indication of what area was being operated on in the body of the note? You use the post-op diagnosis to code, but it's not your only resource. You can use information from the procedure details to help with specificity when the diagnosis listed is vague. Also, you'll need to know if it's a primary malignancy, secondary, or Ca in situ. Without that info, the most specific recommendation I can give you is 239.2, Neoplasm of Skin, NEC, Unspecified.What code would you use for skin cancer, the preop and postop dx only states skin cancer.
New to coding would appreciate the help.
I stand corrected...thanks Debra! I learned something today!According to AHA coding Clinics a statement of Skin Cancer should be coded as the primary site so I would go with 173.9. The 239.X series are codes for when the morphology of the neoplasm has yet to be determined.