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Question: A patient鈥檚 medical record says they have cancer of the neck, but the pathologist鈥檚 report says the neoplasm has 鈥渦ncertain behavior.鈥� What鈥檚 the difference between uncertain and unspecified behaviors in terms of neoplasms?

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Answer: A pathologist鈥檚 report may describe uncertain behavior of a neoplasm if current testing cannot determine or predict the histological behavior of the cancer. In such a situation, the ICD-10-CM Neoplasm Table instructs coders to assign D48.1 (Neoplasm of uncertain behavior of connective and other soft tissue) for cancer of the neck if the pathology report states the specimen鈥檚 behavior is uncertain. This would be because the pathologist cannot provide 鈥渉istologic confirmation whether the neoplasm is malignant or benign,鈥� per the note for the D37-D44 and D48 codes.

According to ICD-10-CM guidelines I.A.9.b, the unspecified behavior codes are used 鈥渨hen the information in the medical record is insufficient to assign a more specific code.鈥� Assign an unspecified behavior code for neoplasms when the provider documents that a patient has cancer but there鈥檚 no specific code assigned for the cancer.

In this situation, you should report a confirmed diagnosis of neck cancer and unspecified behavior of neoplasm with code D49.2 (Neoplasm of unspecified behavior of bone, soft tissue, and skin) if there is no documentation that the cancer is in an anatomic location which has its own, more specific code.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC