Wiki nevus question

[Lashel]

I have a case study in a text book that I am using that says the following:

Assessment: abcess w/cellulitis; nevus of the back

There is documentation for the I/D of the abscess, and then this statement " sandy will be referred to a dermatologist for evaluation of the possible basal cell carcinoma of the back"

I would typically code the mole as a neoplasm of uncertain behavior based on the statement that the physician is referring her for possible basal cell carcinoma. However, the answer key in my instructor manual coded it as benign.

Any thoughts or ideas on that scenario.

 

[ajs]

I have a case study in a text book that I am using that says the following:

Assessment: abcess w/cellulitis; nevus of the back

There is documentation for the I/D of the abscess, and then this statement " sandy will be referred to a dermatologist for evaluation of the possible basal cell carcinoma of the back"

I would typically code the mole as a neoplasm of uncertain behavior based on the statement that the physician is referring her for possible basal cell carcinoma. However, the answer key in my instructor manual coded it as benign.

Any thoughts or ideas on that scenario.

The instructor probably coded it benign because the assessment states nevus of the back. The assessment does not say there is uncertain behavior. The referral is not taken into account when choosing the diagnosis code, just what the provider documented for the encounter.