Don’t let 238/239 confusion leave medical necessity to chance.
You may feel “uncertain” when choosing a neoplasm code which is for a pathology report — however that doesn’t mean the lesion is uncertain.
Mistaking “uncertain” for “unspecified” might cost you, based on payers’ covered diagnosis lists that influence medical necessity decisions. Take a look at medical billing and coding experts’ explanations and examples to ensure you know the difference.
Know the Big Picture
To know the uncertain/unspecified distinction, you need to comprehend the overall neoplasm diagnostic classification scheme. The ICD-9 neoplasm table differentiates cancers as malignant, benign, uncertain, or unspecified.
Let’s begin with the malignant/benign difference, as that’s the key to understanding the “uncertain” classification. Malignant neoplasms are cancerous, and could be noninvasive (in situ), or invasive.
ICD-9 further subdivides invasive cancers as “primary,” implying that the cancer rises from surrounding cells, or”secondary,” implying that the cancer metastasized (spread) from a primary malignancy located somewhere else in the body.
Depending on location, ICD-9 differentiates the cancer types with different codes. For instance, for the female breast areola you would select from the following ICD-9 codes:
- 174.0 – (Malignant neoplasm of female breast, nipple and areola)
- 198.81 – (Secondary malignant neoplasm of breast)
- 233.0 – (Carcinoma in situ of breast)
Benign neoplasms are cancer-free. For instance, for a fibroadenoma of the breast, you must report 217 (Benignneoplasm of breast).
Tip: Don’t report each benign neoplasm by means of the general benign neoplasm code for that body site, for instance ICD-9 code 219.x (Other benign neoplasm of uterus). Select the code based on the specific description from the pathology report, like fibroid tumor as 218.x (Uterine leiomyoma)
Make Certain It’s Uncertain
Benign and malignant aren’t the lone neoplasm classifications available. Sometimes the pathologist identifies a neoplasm that is currently benign but exhibits characteristics indicating that it might becomemalignant,” Stainton says. Because the tumor has an “unpredictable” behavior, it fits a category called “neoplasm of uncertain behavior.” ICD-9 defines these tumors as “histomorphologically well-defined neoplasms, the subsequent behavior of which cannot be foretold from the present appearance.”
Uncertain is not unspecified: Neoplasms of uncertain behavior have very precise histology that the pathologist describes. They are certainly not unspecified.
Recognize key words: In case the pathology report specifies atypia or dysplasia, the neoplasm is “in transition” from benign to malignant and is thus “uncertain.” In case the process continues and the mass goes untreated, the neoplasm could finally become malignant.
Example: Tubular adenomas of the colon are at risk for becoming malignant. In case the pathology report indicates other biopsy conditions, like high-grade dysplasia, you could report ICD9 codes 235.2 (Neoplasm of uncertain behavior of stomach, intestines, and rectum).
You’ll find the codes for uncertain behavior in the following ICD-9 categories:
- 235 – (Neoplasm of uncertain behavior of digestive ad respiratory systems)