Hello
annettebec,
From your statement "phyllodes tumor - low grade" diagnosis assignment.
First it is very important to go to the Index portion of your ICD-10-CM book and locate the term "Tumor".
Next, you need to carefully review all the subheadings in alphabetical order under the term "Tumor" until you reach "phyllodes".
I am reviewing the 2024 AAPC ICD-10-CM Expert edition (page 349) it states:
phyllodes D48.6x
benign D24.x
malignant - see Neoplasm, breast malignant
*Please note the "x" represents that you will need to review & validate within the tabular area of your ICD-10-CM book the correct and complete diagnosis code assignment here.
If there is no mention of benign or malignant tumor within this pathology report; you will clearly fall onto utilizing D48.6x (Neoplasm of uncertain behavior of breast) as your diagnosis assignment for this accession per our ICD-10-CM book.
Just so you know, sometimes after the pathologist's reviews a specimen under a microscope, they are unable to clearly define if the neoplastic process is benign or malignant (they just simply do not know).
That is why there are those diagnosis categories (D37-D44 with D48) within our ICD-10-CM book that deals with this very type of scenario. The pathologist's reviewed the specimen under microscope and provided their final diagnosis and the coder will review the pathology, and then review the index and validate the diagnosis assignment within the tabular to apply the diagnosis for the coding scenario shared above.
Please be sure you are reviewing the Index first within your ICD-10-CM book before just jumping into the Neoplasm Table for diagnosis assignment. I cannot stress this enough.
I am hopeful I shared some light on your coding question this evening,
From your question I would have provided:
CPT 88307 (lumpectomy)
ICD D48.62 (neoplasm of unspecified behavior of left breast)
Thanks for listening and have a great evening,
Dana