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Neoplasms: Unspecified or Uncertain?

  1. #1
    St Louis West
    Talking Neoplasms: Unspecified or Uncertain?
    Medical Coding Books
    I have explained the difference between unspecified and uncertain to our physicians and most are accepting but I have a couple that do not agree. I am looking for rock solid documentation explaining the difference. By rock solid I mean a professional organization or publication. I know we, as professional coders, know the difference but sometimes my "boys" are a little unruly and want to see it in balck and white. Does anyone have a resource?

    Unspecified=specimen not sent to pathology or specimen was sent but report is not back yet
    Uncertain=histologically proven by pathology to be in a transitional state where cells are not normal but are not malignant at the time of submission
    Thanks. Pat:

  2. #2
    Columbia, MO
    I believe it was AHA coding clinic May -June 1985 issue where this was covered completely.
    In that issue they state that unspecified is a working dx that can be rendered after a preliminary diagnostic workup renders a dx of something like a tumor which is a neoplastic process but morphologically yet unspecified. And as you stated the unspecified is a path dx. Also in the codebook but depending on which publisher you have it states under uncertain behavior that these dx are morphohistopathologic. I hope this helps you.

    Debra A. Mitchell, MSPH, CPC-H

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