Bianca Posted Mon 01st of August, 2016 17:05:31 PM
Our dr did a TURBT small on a patient with a hx of high grade bladder cancer and with a positive urine cytology. The path report reads : "Focally reactive, largely denuded urothelial mucosa with
dystrophic calcification and mild chronic inflammation. Negative for
malignancy." Can I use D49.4 for diagnosis?
SuperCoder Answered Tue 02nd of August, 2016 03:38:30 AM
Since the path report read Negative for Malignancy, ICD 10 code D49.4 cannot be used as a diagnosis code. ICD 10 code N32.89 (other specified disorders of bladder like bladder hypertrophy) should be used as the diagnosis code.
Bianca Posted Tue 02nd of August, 2016 11:21:33 AM
if I use that dx the claim will not be paid
SuperCoder Answered Wed 03rd of August, 2016 03:36:56 AM
I did further research and found that D49.4 is the most appropriate ICD 10 code to be billed in this scenario. Also, along with this bill code, please bill ICD 10 code Z85.51 for history of bladder cancer.