vendredi 7 août 2015

coding neoplasms

I am taking a practice proficiency exam and got the question "Patient arrived in ED complaining of having sever RUQ pain, nausea and vomiting x several weeks and a 20 lb weight loss. Tests revealed a mass within the gallbladder. However, no cholecystitis or stones. The patient was admitted and a surgeon was consulted. The next day, a cholecystectomy was performed. The pathology results show the patient to have cancer of the gallbladder. Code the diagnosis for the surgery."

I went to the neoplasm table and then went to gallbladder and then coded it as unspecified behavior.

When I looked up the answer, I was wrong and they coded it as primary malignancy.

Are we to assume a primary malignancy if it is not specified? Thanks!


coding neoplasms

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