What diagnosis code should you use when sending a biopsy within the oral cavity to pathology?
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Rule of documentation:
Categories D37–D44, and D48 classify by site neoplasms of uncertain behavior, i.e., histologic confirmation whether the neoplasm is malignant or benign cannot be made. (you are not diagnosing just suppling the information.
Always look for the 5th character: Anatomic Site. If not, you will have to use an unlisted site and must add more information or back up code to explain to insurance why and where you are performing the biopsy.
5th Character: Anatomic site
You can find codes listed under D37.09 – Neoplasm of uncertain behavior of other specified sites of the oral cavity. If you can not find a more specific code that you must try to explain the area and it must not have a specific code or you will not be paid.
|D37.Ø1||Neoplasm of uncertain behavior of lip|
|Including: vermilion border|
|D37.Ø2||Neoplasm of uncertain behavior of tongue|
|D37.Ø3-||Neoplasm of uncertain behavior of the major salivary glands|
|D37.Ø4||Neoplasm of uncertain behavior of the minor salivary glands|
|Including: submucosal salivary glands of lip, cheek, hard palate, soft palate|
|D37.Ø5||Neoplasm of uncertain behavior of pharynx|
|Including: aryepiglottic fold of pharynx NOS, hypopharyngeal aspect of aryepiglottic fold, marginal zone of aryepiglottic fold If there is a connection to the salivary glands you can use this code which covers different area of the oral cavity. Make sure your codes match the area unless you are using D37.09 Unspecified.|
|D37.Ø9||Neoplasm of uncertain behavior of other specified sites of the oral cavity|
D37.04 – Neoplasm of uncertain behavior of the minor salivary glands
Neoplasm of uncertain behavior of submucosal salivary glands of lip
Neoplasm of uncertain behavior of submucosal salivary glands of cheek
Neoplasm of uncertain behavior of submucosal salivary glands of hard palate
Neoplasm of uncertain behavior of submucosal salivary glands of soft palate
6th Character: Salivary gland affected
- D37.02 – Neoplasm of uncertain behavior of tongue
“If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis.”
When documented please look at the following to add into your notes:
– Functional activity associated with neoplasm
What is the procedure code that is acceptable to use when diagnosing D37.02 Excision Procedures on the Tongue and Floor of Mouth?
Other Procedures on the Tongue and Floor of Mouth
41530 SUBMUCOSAL ABLTJ TONGUE RF 1/> SITES PR SESSION