tci General Surgery Coding Alert - 2019 Issue 5

Reader Question: Focus ICD-10 For Bladder Cancer Dx

Question: Our surgeon took a bladder biopsy using a cystoscope and in the op report, described the specimen as “an adherent stone-like structure with calcification affixed to the right lateral bladder wall, measuring 3.4 mm.” The pathology report gives a diagnosis of “transitional cell carcinoma.” What diagnosis and procedure codes should we use? Arizona Subscriber Answer: You should code the diagnosis to the highest degree of specificity possible, which means reporting an ICD-10-CM code based on the pathologist’s final diagnosis, not based on the surgeon’s description. The correct diagnosis code for transitional...

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