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unclear pathology terminology to code excision

  1. #1
    Default unclear pathology terminology to code excision
    Medical Coding Books
    I am coding an excision of lesion on thigh that was on hold for pathology [CPT 12032, 11402]. The path result diagnosis came back as "atypical compound melanocytic nevus". I would code this as dx 216.7 (benign neoplasm, thigh) - however, the pathology states additionally "the findings are suspicious for MMIS evolving with pre-existing nevus. An atypical compound nevus is a less likely possibility".
    I know that we code to the highest level of specificity, which would not include "suspicious for", however, I have went on different sites that state certain "ambiguous" terms are ok to code. (i.e. appears, consistent with, favors, most likely, typical of) & "suspicious for" was listed, as well.

    I'm just confused on terminology for coding path results - how do you code when there are comments listed on the path report in addition to the main dx?

    Thanks so much!

  2. #2
    I would probably code 238.2 (lesion of uncertain behavior) because the diagnosis still has not been determined.

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