Q&A help required to code this

[asheeth]

Hi,

My instructor gave me this ( bolded and given below) and told me to code it ...he told me simply to code it...but gave me choice saying that I have a choice but should use ICD9 and/or CPT code and I really do not have any idea what to do....!!! seeking your divine intervention...

"moderate to severe dysplasia on cervical biopsy"



thanks in advance....

 

[Ruth Sheets]

Seems ambiguous to me. Clearly you want to code for the dysplasia, but it is not clear to me when the cervical biopsy was done, so I'm thinking they included the "cervical biopsy" part just to clarify that the dysplasia is on the cervix. I'd leave the CPT code out of it, but normally there would be more information to clarify whether the cervical biopsy was done at the visit we are being asked to code for.
The code for moderate dysplasia of the cervix is 622.12. The code for severe dysplasia of the cervix is 233.1. Both these codes excludes the other so if I couldn't get more information from the doctor , I'd code it as 622.10, Dysplasia of cervix, unspecified, because frankly, it wasn't adequately specified!

Not sure this is what the instructor is looking for, but it seems like your instructor is just purposely being ambiguous, so I wouldn't waste too much time on it, and just give it an answer with some sort of rationale behind it.

 

[asheeth]

Seems ambiguous to me. Clearly you want to code for the dysplasia, but it is not clear to me when the cervical biopsy was done, so I'm thinking they included the "cervical biopsy" part just to clarify that the dysplasia is on the cervix. I'd leave the CPT code out of it, but normally there would be more information to clarify whether the cervical biopsy was done at the visit we are being asked to code for.
The code for moderate dysplasia of the cervix is 622.12. The code for severe dysplasia of the cervix is 233.1. Both these codes excludes the other so if I couldn't get more information from the doctor , I'd code it as 622.10, Dysplasia of cervix, unspecified, because frankly, it wasn't adequately specified!

Not sure this is what the instructor is looking for, but it seems like your instructor is just purposely being ambiguous, so I wouldn't waste too much time on it, and just give it an answer with some sort of rationale behind it.

Thank you m'am .....what got me confused in first place was "moderate to severe" and I had to seek help at here forum ... but your explanation and rationale seems enough to challenge instructor word play...

PS: my instructor sometimes gives us these kind of crazy confusing sentences ....

 

[Ruth Sheets]

Let us know what your instructor thinks. Sometimes the lectures give hints and other times they ask a question like this so that everyone who gets it wrong will be more motivated to listen to the lecture explaining their answer. Hopefully we all learn something!