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
Q55.64 Hidden Penis
Buried penis
Concealed 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.