Diagnoses Codes: Be Well-Versed With 'Uncertain Behavior'

If you always use diagnosis code 238.2 while reporting 11100 for a biopsy procedure your physicians carry out, you are setting your practice up for a rough ride. The key to understanding when to use the 'uncertain behavior' diagnosis code is understanding what the code descriptor really means. Here are some expert tips to see to it that you are selecting the proper diagnosis code for all your 11100 claims.

Prior to choosing a code, wait for pathology

When your physician carries out a biopsy, you should always wait until the pathology report comes back to select the proper diagnosis and procedure codes to report, although this'll not always have an impact on the CPT code you'll end up choosing.

Here's why: The biopsy specimen's pathology will impact the ICD-9 code you report; however most CPT procedure codes aren't based on the specimen's results. There are some CPT codes which are linked to specific diagnoses; however overall CPT is about what you did while ICD-9 is about the outcome or the reason for it.

Understand meaning behind 'uncertain' codes

When you report 238.2 as the diagnosis for a biopsy procedure, you are telling the payer that the pathologist said in his path report that he was not certain as to the morphology of the lesion.

Uncertain behavior does not mean the coder is not sure or that the physician thinks the lesion looks suspiciously; however it might be benign. Uncertain behavior means that a specimen has been examined by a pathologists and that the cells are of mixed types.

How it functions: Uncertain behavior diagnoses are right for specimens identified as hyperplastic or precancerous. If you submit a claim with 238.2 as a diagnosis before you have the pathology report back, you may have actually told the insurer that the patient has a disease process that he does not actually have or may have, however hasn't been confirmed as yet.

Unspecified versus uncertain: If you're not sure what a lesion is, you use unspecified, not uncertain; uncertain is reserved for a pathologist only diagnosis.

Rushing into coding just to get paid? It's a no

You should never code just to make sure you will be paid for a procedure. In case of a biopsy, waiting to code until you have the pathology report shouldn't affect your payment anyway. You may have to wait a bit longer to see the reimbursement if you need to hold a claim while you wait for the pathology report, however your coding will be much more spot on.

For more on this and for other updates on diagnosis codes, sign up for a good medical coding resource like Supercoder.