Gross description: Specimen labeled as congenital lesion, left neck. Specimen consists of a tan excised piece of skin measuring 18 x 8 x 8 mm. The specimen is inked and bisected. Submitted in single cassette.
Microscopic diagnosis: Sections are of a polypoid piece of skin lined by squamous epithelium without dysplasia or melanocytic hyperplasia. The dermis is unremarkable. The central portion of the polypoid structure has cartilage without diagnostic abnormality. No cysts, granulomas, nevus or malignancy noted.
Final diagnosis: Accessory Tragus
The guidelines have not changed from ICD-9 to ICD-10 for coding congenital anomalies however they did change where to find them in the code book. ICD-9 listed them in Chapter 14 however, in ICD-10 they are listed in Chapter 17. The key to assigning congenital anomaly codes from Q00-Q99 is they must be documented in the medical record.
- 2014 ICD-9-CM Professional Manual (AMA) page 7 (vol 2/alpha), 239 (vol1/tabular)
- 2015 Draft ICD 10-CM Manual (AMA) page 9, 775