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Wiki Neoplasm coding

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Lynda Wetter

Lynda Wetter

True Blue
Local Chapter Officer
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I remember being told we cannot code a malignancy without final pathology.
For example Physician sees a patient for a lesion on the leg and referrs to dermatology for what he says looks like malignancy. That provider cannot code malignant. Where can I find that in the ICD guidelines. Or would that fall under not coding possible, rule out suspcted dx's?
 
If the dr's documentation states "probable" "possible" "rule out" you cannot use that code. I have always held the claim until the path report comes back.
Hope this helps!

Teresa
 
Uncertain Diagnosis

Hi,


Yes. You can't code qualified conditions (?probable?, ?suspected?, ?likely?, ?questionable?, ?possible") until confirmed by provider.

In ICD-9-CM, section-II (selection of principle guidelines) part having guidelines for qualified conditions below the title of Uncertain Diagnosis.



Regards,

Dhanesh M
 
neoplasm coding

If the report states "consistent with" ependymoma- can this be coded as a definitive diagnosis?

Thanks
 
"Consistent with"

If the pathology report states "consistent with" ependymoma - that is not codeable. Was anything else stated in the pathology report?
Thanks,
Dana Chock, CPC, CCA, CANPC, CHONC, CPMA, CPB
Anesthesia, Pathology & Laboratory coder
 
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