• My Account
    • Login
  • Contact Us

CodingIntel

Medical coding resources for physicians and their staff. CodingIntel was founded by consultant and coding expert Betsy Nicoletti.

  • Join Today
  • What is CodingIntel
    • About
    • Become a Member
    • FAQ
  • Pricing
  • Free Resources
    • Overview
    • Blog
    • Everyday Coding Q&A
    • Newsletter
    • Can I get paid
  • Coding Library
    • Coding Guides
    • Quick Reference Sheets
    • E/M Services
    • How Physician Services Are Paid
    • Prevention & Screening
    • Care Management & Remote Monitoring
    • Surgery, Modifiers & Global
    • Diagnosis Coding
    • New & Newsworthy
    • Speciality
    • Practice Management
    • E/M Rules Archive
  • Webinars

March 29, 2023

Diagnosis coding for biopsy sent for pathology

Print Friendly, PDF & Email

Question:

What diagnosis code should you use when sending a skin biopsy to pathology?

a)  D48.5 Neoplasm of uncertain behavior of skin, or

b)  D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin

Answer:

The answer is b! Use an unspecified code when a specific diagnosis code is not known at the time of encounter. This is a common mistake I see in dermatology, general surgery and primary care.

Uncertain has a specific meaning in ICD-10. It means that the specimen has been examined by the pathologist and it can’t be determined if the neoplasm is benign or malignant. An uncertain neoplasm is reported after the pathologist’s report, not when sending the specimen for biopsy.

According to ICD-10, there are specific categories of codes that are used for neoplasms of uncertain behavior. They are:

  • D37
  • D44
  • D48

These classify the neoplasm by site and should be used when “i.e., histologic confirmation whether the neoplasm is malignant or benign cannot be made.”

Unspecified, on the other hand, means that a definitive diagnosis cannot be made at the time of the encounter.

The general guidelines say,

“If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis.”

This is exactly the situation when a biopsy is taken and sent for pathology.

This is confirmed in the general guidelines related to neoplasm.

“Chapter 2 of the ICD-10-CM contains the codes for most benign and all malignant neoplasms. Certain benign neoplasms, such as prostatic adenomas, may be found in the specific body system chapters. To properly code a neoplasm it is necessary to determine from the record if the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior.”

The word uncertain is related to a histologic determination. It doesn’t describe “we aren’t sure so we are sending it to pathology.”

Here are links to more about diagnosis coding and specialty specific services

  • Coding for biopsy | Should we wait for pathology?
  • Diagnosis Coding | Not just for claims anymore
  • Roadmap to dermatology coding

Get more tips and coding insights from coding expert Betsy Nicoletti.

Subscribe and receive our FREE monthly newsletter and Everyday Coding Q&A.

Sign up

We will never share your email address. Unsubscribe anytime.


 

Last revised December 16, 2021 - Betsy Nicoletti
Tags: general surgery_diagnosis coding, ICD-10 coding, primary care_diagnosis coding

CPT®️️ is a registered trademark of the American Medical Association. Copyright American Medical Association. All rights reserved.

2023 E/M reference sheets

These handy quick reference sheets included at-a-glance MDM requirements for office, hospital, nursing home and home and residence services. And, a bonus sheet with typical time for those code sets. Sign up for Betsy’s monthly newsletter to download these reference sheets and share them with your practitioners.

Sign Up Now

2023 E/M guidelines for hospital, nursing facility, home and residence services | Webinar

Effective January 1, 2023, the AMA has revised the definitions and guidelines for hospital and other E/M services, including ED visits, nursing facility services, home services, and domiciliary care codes. Also, coding for prolonged care services gets another overhaul with revised codes and guidelines. Watch this webinar about all these changes.

Watch it now

Latest Intel

Coding for hospital services | Webinar

Coding for hospital services April 20, 2023 … Read More...

CMS Split/Shared Services Rules | Reference Sheet

Download Reference Sheet Split/shared services … Read More...

Chronic Care Management | Reference Sheet

This quick reference sheet includes clinical staff … Read More...

Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse | HCPCS Code G0442

The  US Preventive Services Task Force (USPSTF) … Read More...

Browse By Categories

Browse Content

  • Articles
  • Coding Guides
  • Everyday Coding Q&A
  • Videos
  • Can I Get Paid to
  • Blog
  • Webinars

Tags

behavioral health_cpt codes behavioral health_E/M services care management CMS updates Code sets and reimbursement compliance issues CPT codes for preventive services CPT updates critical care services dermatology_essential resource dermatology_procedures E/M frequency data E/M medical decision making E/M overview E/M reference sheets FQHC general surgery_diagnosis coding general surgery_E/M services general surgery_modifiers general surgery_procedures global surgery issues HCC diagnosis coding hospital inpatient/observation ICD-10 coding level of service_history level of service_MDM level of service_time medicare incident-to and shared services minor procedures modifiers newborn care office and other E/M Preventive and problem visits preventive services for medicare primary care_diagnosis coding primary care_E/M services primary care_essential resource primary care_modifiers primary care_other E/M services primary care_preventive services primary care_procedures remote physiologic monitoring screening and counseling for behavioral conditions teaching physician rules telehealth

All content on CodingIntel is copyright protected. Any resource shared within the permissions granted here may not be altered in any way, and should retain all copyright information and logos.

  • What is CodingIntel
  • FAQs
  • Terms of Use
  • Privacy Policy
  • Contact

Our mission is to provide up-to-date, simplified, citation driven resources that empower our members to gain confidence and authority in their coding role.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.

Copyright © 2023, CodingIntel
Privacy Policy