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Coding results of path report

  1. #1
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    Default Coding results of path report
    Medical Coding Books
    Suggestions on what you would code "Severely atypical glands supsicious for adneocarcinoma." This was from a transverse colon biopsy in a patient with h/o colon ca.

  2. #2
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    I would call the pathologist and ask for their help, or use a 235.2 for uncertain behavior.
    Susan Ward, CPC, COC, CPC-I, CEMC, CPCD, CPRC
    AAPC ICD-10 Expert Trainer
    susanwardcpc@live.com

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  3. #3
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    you cannot use uncertain behavior because that is not what the dx is per the pathologist. I go with the hx of colon cancer as the dx, since we cannot code uncertain dx.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
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    Quote Originally Posted by mitchellde View Post
    you cannot use uncertain behavior because that is not what the dx is per the pathologist. I go with the hx of colon cancer as the dx, since we cannot code uncertain dx.
    Debra;

    My understanding when dealing with path results that come back with a "pre-cancerous" conclusion that you would code uncertain behavior as this is not benign and not malignant. I would still use the 235.2 along with the history of colon cancer. As of right now there are no diagnostic codes that specify otherwise.
    Susan Ward, CPC, COC, CPC-I, CEMC, CPCD, CPRC
    AAPC ICD-10 Expert Trainer
    susanwardcpc@live.com

    A small act of kindness a day can make someone's day special

  5. #5
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    neoplasm of uncertain behavior is a dx that can be determined by the pathologist, it is for when the cellular activity is uncertain, but they must state it, not infer it. I worked in he cancer center for many years and the pathologist warned the coders repeatedly about the use of the uncertain dx codes. The hx of ca is a good code to use, especially if the bx was performed to see if there was recurrence or metastatic invasion. It is quite possible that this is metastatic and by stating uncertain you are indicating the possibility of a new type of neoplasm. So no I would not recommend using that code.

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
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    Neoplasms of an Uncertain Behavior are those for which the final behavior can't be determined at the time of biopsy because the cells may be undergoing malignant transformation. Which means a clear distinction between malignant and benign can't be made. Rhondar indicted that the path report was in hand and Severely atypical glands suspicious for adenocarcinoma seems to fall into the uncertain behavior category. It may indicate the possibility of a new type of neoplasm but doesn't preclude a final DX of metastatic CA if that is the ultimate finding.

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