"Probable BCC" ?? How to dx code?

Orthocoderpgu

True Blue
Local Chapter Officer
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Salt Lake City, UT
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I get the path report back and it states: "Probable BCC". It's either benign or malignant. How do we code this when the Pathologist states that it is probable BCC? Any thoughts?
 
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New Orleans, LA
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You don't have anything definitive to code here. Based on just the statement "probable BCC" you cannot even say it is a neoplasm unless there is more to the report than this statement. 795.4 would be appropriate for this smidge of diagnostic findings: non-specific abnormal findings. It reports what the pathologist found without committing, just like the dx. I would put the clinical indications secondary to flesh out the coding and provide more information. An unsatisfactory bit of coding, but one based on the available documentation.

Cheers,
WK
Surgical Pathology Coding Blog
 
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