AHA Coding Clinic® for ICD-9 - 2006 Issue 1; Ask the Editor
Correct Coding of Mass or Lesion
When coding a diagnosis documented as a mass of a particular site and that site is not listed under the main term “Mass†is it appropriate to look under the term “Lesion†and if not found under “Lesion†should we refer to the site in the Table of Neoplasms? ...
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Article Overview
This article explains how to approach diagnosis lookup questions involving nonspecific terms used in documentation and how to navigate related indexing references in ICD-10-CM. It is intended for coders who need general guidance on finding the appropriate diagnosis code path when the documented term is broad or incomplete. The article focuses on index navigation, cross-references, and when not to jump to other code selection resources.
Why This Topic Matters
Nonspecific documentation terms can lead to incorrect diagnosis code selection if the coder uses the wrong index pathway. Understanding the article helps coders and auditors evaluate whether a diagnosis should be traced through the indexing structure or through a different reference source.
Article Sections
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Question about indexing a mass or lesion diagnosis
Introduces a coding question about where to begin when documentation uses a nonspecific finding term for a particular site.
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Guidance on cross-references and index lookup
Discusses the general approach to following index references and related terminology when the documented diagnosis is broad or incomplete.
What You Will Learn
- How the article frames diagnosis lookup for broad finding terms
- How cross-references in the index are part of the discussion
- What general coding reference pathway the article addresses
- Why nonspecific documentation terms can create indexing questions
Who Should Read This
- Medical coders
- Coding auditors
- Billing staff
- Clinical documentation specialists
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