tci General Surgery Coding Alert - 2012 Issue 2

Reader Question: Save 'Uncertain' Neoplasm for Specific Diagnosis

Question: When one of our surgeons removes a breast mass, he insists on putting the diagnosis in the op report "uncertain behavior neoplasm, breast" if the pathology report is not back. When is it appropriate to use this diagnosis, as opposed to "breast mass?"Texas SubscriberAnswer: You should not use an uncertain behavior code, such as 238.3 (Neoplasm of uncertain behavior of breast), unless the surgeon has reviewed the pathology report and confirms that the neoplasm meets certain characteristics. In the scenario you describe, a code such as 611.72 (Lump or mass in breast) would be more...

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