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Not sure what Dx code to use for this report?

  1. #1
    Question Not sure what Dx code to use for this report?
    Exam Training Packages
    Physician used codes 611.72 and 611.8 but I'm not too sure if additional or different codes should be used:

    Within the palpable area of concern in the right axilla, there are several
    lymph nodes which are enlarged. The largest lymph node measures 2.1 cm in
    greatest dimension and there is diffuse cortical thickening. The lymph node
    maintains its normal reniform shape.

    Enlarged right axillary lymph node which likely accounts for the palpable
    area of concern with associated tenderness. Findings are likely explained
    as reactive adenopathy in the setting of an ipsilateral infection.

    Thank you,

    Salima H., CPC

    Radiology Coding Specialist

  2. Default
    I go with 611.72...

    Nalini CPC

  3. Cool Re:- one info
    Hi Nalini could you answer my question.. I am going for cpc certification this month. I am seeking one information that i went through cpt book of current year so i came across some intial pages of the book in which some info was given about some of the selected procedurcs like endoscopic, laproscopy, arthoscopy (from every part) apart of these things some illustrations of anatomy figures & few pre-fix suffix, wordroots were given so what purpose are they given here menas for examination point of view are they main....plz respond.

    what are the main things i need to follow in terms of preperation to get through this examination.

    Thanks & Regards
    Nikhil Jain

  4. #4
    Since the provider states 'lymph nodes', you may want to look at 785.6

    2009 ICD-9-CM Diagnosis Code 785.6
    Enlargement of lymph nodes

    ICD-9-CM Volume 2 Index Entries That Refer To 611.72
    Lump - see also Mass
    breast 611.72
    Mass breast 611.72
    Swelling 782.3
    breast 611.72

    If the provider wasn't sure that it was a lymph node, I would use the breast mass, but because he stated 'several axillary lymph nodes' I'd lean more toward 765.6

    Either way, I don't believe the claim would deny because the provider did find an abnormality.
    The Oracle

  5. #5
    Stuart, Florida
    I agree with using 785.6 since it specifically states "Enlarged right axillary lymph node". 611.72 and 611.8 are not supported by, either, the Findings or Impression.
    Vanessa Mier, CPC

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