Wiki Prostate Cancer Diagnosis ?

RebeccaB

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One of our physicians saw a patient (medicare) and thinks its prostate cancer, patient refuses a prostate biopsy, Dr wants to start patient on Eligard/Firmagon injections
Can you use the diagnosis of prostate cancer without it being confirmed by biopsy ?
I have not been able to find anything that states the biopsy must be done for the cancer diagnosis

Any help much appreciated
Thanks
Rebecca
 
Per the ICD-10 guidelines, facilities may code uncertain diagnoses for inpatient claims only, physician or outpatient facility may not: "Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit."

If the physician has documented that they 'think' it is prostate cancer, that is an indication of uncertainty and shows that the provider is using it as a working diagnosis rather than a confirmed diagnosis, and it would not be appropriate to code a prostate cancer. If, however, the physician has documented they have actually diagnosed the patient with cancer, but the documentation does not reflect that the diagnosis has been confirmed with a pathology report, I would either query the physician for clarification or refer the encounter to a supervisor, because to my knowledge it is not possible for a physician to render a diagnosis of a malignancy without a pathology report. I don't know of any documentation to support this rule, but considering the severity and implications of this kind of a diagnosis, it requires a special kind of attention and is important to get this one correct.
 
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