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atypical Nevi appropriate dx

  1. Default atypical Nevi appropriate dx
    Medical Coding Books
    A patient has a clinically atypical nevus. What would be a more appropriate diagnosis 448.1 or 238.2?

  2. #2
    Augusta, Georgia
    Per ICD-9-CM index.. nevus indexes to neoplasm, benign, skin... which would code to 216.9 . If you have the specific anatomic site.. you would be able to assign a more specific 4th digit on your code.

    The term "clinically atypical" .. either together or alone is not a subterm under nevus.. so we can't assume uncertain behaviour and take it to 238.2. It was not described an non neoplastic so can't use 448.1.

    In googling.. atypical nevus.. I found also known as dyplastic nevus , atypical mole or atypical melanocytic mole.. none of these terms index to uncertain behaviour under nevus or mole..

    Also.. information on this is that in some cases atypical nevus may develop into skin cancer but the vast majority do not become malignant..

    So.. per indexing (and validated by clinical info)... 216.9 is best code.. but specified by 4th digit to site if location is documented.
    Michelle Cowart, MPH, RHIA, CCS, CPC, CPC-I, CIC
    AHIMA Approved ICD-10-CM/PCS Trainer/Ambassador
    Director of Operations, All About Coding, LLC
    Licensed AAPC-PMCC Site
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