Clinical History: Nausea, Epigastric Pain
Gross Description: Received in formalin, designated "Gastric biopsies," are two fragments of light tan mucosal tissue, each measuring approximately 0.3 cm in greatest dimension, entirely submitted in a single cassette.
Microscopic Diagnosis: Negative for intestinal metaplasia, dysplasia, or malignancy.
What are the appropriate diagnosis codes?
For diagnostic tests interpreted by a physician, code first any confirmed or definitive diagnoses documented in the pathology report. As in this scenario, when a definitive diagnosis is not rendered, the code selection is based on the clinical history or pre- post-operative diagnoses information provided by the referring physician.
The ICD-9-CM and ICD-10 Coding Guidelines for Diagnostic Coding and Reporting Guidelines for Outpatient Services are very clear in directing the coder for this scenario; "codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider." 1 2