tci General Surgery Coding Alert - 2022 Issue Q3

You Be the Coder: Avoid Dx Terms of ‘Uncertainty’

Question: In the office, our surgeon aspirated a painless “lump” behind the patient’s ear and submitted the fine needle aspirate for pathologic diagnosis. The pathology report stated that the cellular material was “consistent with” Pilomatrixoma. How should we code the diagnosis? Iowa subscriber Answer: You should report the diagnosis as R22.1 (Localized swelling, mass and lump, neck). You should not code this as confirmed pilomatrixoma (D23.4, Other benign neoplasm of skin of scalp and neck) Here’s why: For outpatient services, ICD-10-CM Official Guidelines, Section IV.G, states, “Do not code diagnoses documented...

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