Annette Posted Mon 23rd of September, 2019 10:29:56 AM
SKIN, RIGHT FOREARM, PUNCH BIOPSY:
- Most consistent with low grade B-cell lymphoma, see comment
COMMENT: Sections show a deep dermal infiltrate of B- and T-cells with scattered
atypical cells which focally cluster in a region of the superficial-most aspect of the
infiltrate. Occasional eosinophils and histiocytes are also present. The B-cells are small
to intermediate in size and do not express CD10, BCL6, BCL2, CD5, or CD43. B-cell gene
rearrangement studies demonstrate both heavy and light chain clonality; T-cell receptor
gene rearrangement studies are borderline/equivocal. These results will be added as an
addendum. The overall findings are most consistent with a primary cutaneous low grade
B-cell lymphoma, favoring marginal zone lymphoma WHAT ICD10 WOULD YOU ASSIGN THANK YOU
SuperCoder Answered Tue 24th of September, 2019 04:50:30 AM
As per ICD-10-CM guidelines, diagnoses documented as probable, suspected, questionable, ruled out, working, consistent with or other similar terms that indicate uncertainty cannot be coded. Since, it is mentioned in the provided report, "findings are most consistent with a primary cutaneous low-grade B-cell lymphoma", it cannot be billed. However, until unless there is no definitive diagnosis, it cannot be coded. Instead, code the conditions to the highest degree of certainty for the patient's encounter. In this situation you can code sign and symptoms and/or patient's indication from the medical documentation.
Hope this helps!