Question Which grade to code

EYacoback

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I'm new to pathology coding. The pathologist will often grade lesion or biopsies specimen that are dysplasia like VIN or VAIN as II/III. When they do that which one am I suppose to code the lesser or the greater? Is there a guide somewhere that can show me those kinds of guidelines?
Thank you
eyacoback
 

danachock

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Hi EYacoback,
I would like to review the comments (if stated) the pathologist made after stating VIN II/III or VAIN II/III but based solely on your statement above - this is entirely my opinion (and anyone OR coder; that simply didn't respond to your request since 4/2/2020 you may feel free to chime in your opinion now) but in my opinion and professional coding experience you would want to code the VIN III or VAIN III that is the greatest level of detail (specificity).
It is simply stated that in their interpretation that the patient had areas of both class II and III that were BOTH identified. If you were to review the SEER websites both VIN or VAIN II or III are considered (although not reportable in their line of work) "high grade" dysplasia and that is simply how I would code this.
I do apologize for my delay in responding and have a great evening.
Dana Chock, CPC, CANPC, CHONC, CPMA, CPB
 
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