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pajohnson

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Can some one who is more familiar with pathology explain what this means, and what ICD-10 code you would use....
GASTRIC ANTRAL AND OXYNTIC MUCOSA WITH CHRONIC INACTIVE GASTRITIS; NEGATIVE FOR HELICOBACTER PYLORI TYPE ORGANISMS BY IMMUNOHISTOCHEMISTRY, and SQUAMOUS MUCOSA WITH REFLUX ESOPHAGITIS, NEGATIVE FOR FUNGAL ORGANISMS BY GMS
Thanks in advance.
 
GASTRIC ANTRAL AND OXYNTIC MUCOSA WITH CHRONIC INACTIVE GASTRITIS: pt has chronic gastritis with no acute signs present = K29.50

NEGATIVE FOR HELICOBACTER PYLORI TYPE ORGANISMS BY IMMUNOHISTOCHEMISTRY: CLO test negative

SQUAMOUS MUCOSA WITH REFLUX ESOPHAGITIS: GERD = K21.9

NEGATIVE FOR FUNGAL ORGANISMS: candidasis test negative
 
Agree, except:
K21.0 Gastro-esophageal reflux disease with esophagitis

K21.9 Gastro-esophageal reflux disease without esophagitis
 
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Dx needed

What about this one: *STOMACH, ANTRUM, BIOPSY: GASTRIC ANTRAL MUCOSA WITH MILD REACTIVE CHANGES; NEGATIVE FOR HELICOBACTER PYLORI TYPE ORGANISMS.
Thanks for your help,
 
I think you would have to code the symptom(s) that prompted the test for this one. The test was negative, and there is no diagnosis based on pathology to indicate a condition. Or use K31.9 disease of stomach and duodenum, unspecified.
 
pajohnson said:
What about this diagnosis NEGATIVE FOR RESIDUAL ATYPICAL MELANOCYTIC PROLIFERATION?? Would I use the D22 code?
Click to expand...

In that case I personally would code it as Z87.2 personal hx of diseases of the skin and subq tissue being that it is clear the patient has a history of it but doesn't have it as of now.
 
whitney1802 said:
In that case I personally would code it as Z87.2 personal hx of diseases of the skin and subq tissue being that it is clear the patient has a history of it but doesn't have it as of now.
Click to expand...

Also if the diagnosis is melanocytic proliferation I use L81.4, other melanin hyperpigmention.
 
pajohnson said:
What about this diagnosis NEGATIVE FOR RESIDUAL ATYPICAL MELANOCYTIC PROLIFERATION?? Would I use the D22 code?
Click to expand...

This sounds like it was a re-excision from a prior biopsy. If that is the case, you would code for whatever the original biopsy showed.

As a stand-along diagnosis, I would code "atypical melanocytic proliferation" or "melanocytic proliferation" D48.5 (neoplasm of uncertain behavior). This is based on a consult with a dermamtopathologist.
 
A note of caution

I would be very careful about coding negative pathology findings unless the gastroenterologist was specifically looking for a condition which the patient had a definite prior history of (e.g Barrett's esophagus or Crohn's disease). The indication for the procedure will clue you in to such pre-existing conditions.

Otherwise, the negative findings you mention are very common (e.g negative H. pylori) and there is a risk of mistakenly implying that the patient had some prior condition, when in fact, this is just normal "pathologist-speak" on any EGD biopsy.
 
bbooks said:
This sounds like it was a re-excision from a prior biopsy. If that is the case, you would code for whatever the original biopsy showed.

As a stand-along diagnosis, I would code "atypical melanocytic proliferation" or "melanocytic proliferation" D48.5 (neoplasm of uncertain behavior). This is based on a consult with a dermamtopathologist.
Click to expand...

You should never code a diagnosis for pathology that the report indicates is not present. You can code the personal history code or my favorite is to code the Z03.89 for condition not found.
 
I should have been more specific. This thread contains two separate questions. For future reference, if you have a new question, it's best to start a new thread.

Concerning re-excision of skin lesions. If you have the documentation that the biospy was performed as a re-excision, and the pathology is negative, then you should use the original pathology diagnosis for ICD-10. This recommendation is in line with the rule that if you have no pathological diagnosis, use signs/symptoms to code ICD-10.

For example. A biopsy shows a basal cell carcinoma with positive margins, and a wide excision is recommended. The wide excision is performed and it shows no residual carcinoma. Because the indication for the procedure was basal cell carcinoma, that is the ICD-10 code that should be used for the re-excision. Again, though, there must be documentation of the original diagnosis.

I hope that's clearer.
 
Now I am confused. I assumed since it was the same poster that this was also a question regarding coding a pathology report. If you are coding the pathology report you would not code the neoplasm as the report indicates it is no longer present, I use the Z03.89 as they were looking for residual neoplasm but it has now been ruled out with the history of neoplasm secondary. When coding pathology you must code for what the pathologist documented. If you are coding the re-excision for the physician that performed the re-excision then yes you would use the D48.5 code.
 
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