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Need Help with Dx from Pathology reports

  1. Default Need Help with Dx from Pathology reports
    Medical Coding Books
    I'm fairly new to coding from patholgy reports and I really hoping for some advice. Our Doctor performed an excision of a lymph node which came back as a metastic carcinoma with an unknown primary site. As a result he performed a tonsillectomy and a laryngoscopy with a biopsy. When the pathology came back there wasn't really any solid Dx for the tonsil or the biopsy performed, just tissue. How should I code these diagnosis ???
    I would really appreciate any advice given on this.
    Thanks in advance for all responses.

  2. Default
    Code the lymph node as a secondary site. 196._ Primary site unknown. 199.1. Code the tonsils using the reason for the biopsy; the results of the lymph node. 196._

    Darcy Hughes, CPC
    Senior Pathology Coder

  3. Smile
    Thanks for your help, that was my original thought too, I just needed some good direction

  4. #4
    Columbia, MO
    I would do the same, remember the primary must always accompany the secondary site even if unknown.

    Debra A. Mitchell, MSPH, CPC-H

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