Q. As a coder, when do I code for uncertain versus unspecified behavior?
A. Uncertain behavior is a diagnosis that is rendered by the pathologist when the cellular activity observed is uncertain to its morphology. Unspecified is sometimes called a working diagnosis, and is used when a preliminary diagnostic workup is inconclusive, most commonly used when the decision comes back as a tumor. You use the unspecified diagnosis until further workup reveals the morphology of the anomaly. For instance when the physician states it is a tumor then we can know that the physician knows this is not a cyst or an abscess but is definitely neoplastic but yet to be specified by definitive workup as to benign or malignant.
Q. What ICD-10-CM code(s) do I use to report an abnormal digital rectal exam (DRE)?
A. There are several diagnosis codes that can be used to report this service. They are:
|N40.2||Nodular prostate without lower urinary tract symptoms (LUTS)|
|N40.3||Nodular prostate with lower urinary tract symptoms (LUTS)|
|N42.89||Other specified disorders of the prostate|
Q. How do I code for a concealed penis?
A. The proper diagnosis code(s) would be:
|Q55.6||Other congenital malformation of penis|
Excludes 1 acquired buried penis (N48.83)
The AUA has many ICD-10-CM products that are offered to our membership and may be beneficial to your practice.