Wiki Need Help with Dx from Pathology reports

[bella2]

Hi,
I'm fairly new to coding from patholgy reports and I really hoping for some advice. Our Doctor performed an excision of a lymph node which came back as a metastic carcinoma with an unknown primary site. As a result he performed a tonsillectomy and a laryngoscopy with a biopsy. When the pathology came back there wasn't really any solid Dx for the tonsil or the biopsy performed, just tissue. How should I code these diagnosis ???
I would really appreciate any advice given on this.
Thanks in advance for all responses.
Bella

 

[darcy.hughes]

Code the lymph node as a secondary site. 196._ Primary site unknown. 199.1. Code the tonsils using the reason for the biopsy; the results of the lymph node. 196._

Darcy Hughes, CPC
Senior Pathology Coder

 

[bella2]

Thanks for your help, that was my original thought too, I just needed some good direction

 

[mitchellde]

I would do the same, remember the primary must always accompany the secondary site even if unknown.