Health data standards and systems

If a patient is admitted for excision of ganglion but at operation no ganglion, no other abnormality, was identified, do we code just pain in wrist for the diagnosis and incision of skin for the operation?

Operation report details: Presenting Complaint = Excision of ganglion left wrist (over radial pulse)

Details of operation performed = Exploration of presumptive ganglion. Volar aspect of L wrist – no ganglion found or any other abnormality found. Closure.

This query was originally published in Feburary 2004 and previously retired on 30 June 2010. It was reinstated effective 1 July 2020 following a review as the advice is considered current.

The Committee referred to previously published information:
Victorian Coding Newsletter, July 1997
#1164 Admission for excision of lesion, no longer present

Coding Matters, January 1997, (Vol 3 #3 p16)
Questions raised at the national NCC workshops held in May 1996

In the Committee’s opinion, if the patient presented with a symptom, such as pain in wrist, then this should be the principal diagnosis, as directed in ACS 0001 Principal diagnosis:
Codes from the Z03.0–Z03.9 series, Medical observation and evaluation for suspected diseases and conditions, ruled out.
If symptoms related to the suspected condition are noted, then the symptom codes should be assigned, not code Z03.-.

However, if no symptoms are documented, assign
Observation (for) Z04.9
- suspected (undiagnosed) (unproven)
- - condition NEC Z03.8

With only the information provided in the query, the procedure should be coded as:
Incision
- soft tissue NEC 90568-02 [1559]

Z03.8 Observation for other suspected diseases and conditions
90568-02 [1559] Incision of soft tissue, not elsewhere classified