Health Information Management

Coding for an atypical small acinar proliferation of the prostate

HIM-HIPAA Insider, July 9, 2012

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A: The ICD-9-CM index does not include a reference for this diagnostic statement. Submit a query regarding the clinical significance of the statement, referencing 602.3 and including its description. Provide the following information in your query:

  • Clinical indicators, as advised in AHIMA’s practice brief, “Managing an Effective Query Process”
  • The diagnosis
  • Request for clarification that indicates the lack of a diagnosis code for this diagnosis
Ask which of the following best describes the patient’s condition:
  • Dysplasia of prostate
  • Neoplasm of prostate—if so, is neoplasm:
    • Malignant, primary
    • Malignant, secondary
    • Malignant, in situ
    • Benign
    • Undetermined
    • Unspecified
  • Other diagnosis regarding atypical small acinar proliferation of the prostate (please specify) _______
  • Unable to be determined
Editor’s note: Jean Stone, RHIT, CCS, coding manager at Lucile Packard Children’s Hospital at Stanford in Palo Alto, Calif., answered the previous question in the July issue of Briefings on Coding Compliance Strategies.



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