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Benign neoplasm help

  1. Default Benign neoplasm help
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    Hi there - my provider saw a patient in the office for a "painful left posterior knee mass." After an exstensive HPI and physicial exam, my provider diagnosed the knee mass as a "benign neoplasm." Here is the discussion for this visit:

    "I suspect that she may have a small lipoma on the posterior aspect of her leg that has most recently become noticeable due to her weight loss. Alternatively, this could represent a deeper varicose vein given the size discrepancy with supine positioning. In any event, it does appear to be a benign neoplasm, and she was reassured of this. I requested an ultrasound of the area in order to target a discrete lesion for which excision would be reasonable, in an effort to control her pain. She will return to see me following her ultrasound for further discussion."

    The dx she selected was 215.3, benign Neoplasm of the connective/soft tissue of lower limb, since she is treating the mass as such. What do you think - is it okay to you a benign neoplasm code in this case?

  2. #2
    Salt Lake City
    I would code it uncertian behaivor until all the tests are done. 238.1
    Jenifer McPolin CPC, CPMA, RCC

  3. #3
    Columbia, MO
    you cannot code a neoplasm of uncertain behavior as that dx must be rendered by pathology. you cannot code the benign neoplasm as the documentation indicates it is an unconfirmed suspicious dx. you will need to stay with a code for knee mass or lump.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Crystal Lake, IL
    Only "confirmed" diagnoses are to be coded in the physician and/or outpatient setting, therefore, you can only code "knee mass," according to the information provided.

  5. #5
    Agree with not using neoplasm code. You may want to try 719.66 or 782.2

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