What action should a coding professional take when a dermatologist documents a skin lesion that is probable basal cell carcinoma?

When a dermatologist documents a skin lesion as "probable basal cell carcinoma," the appropriate action is to code only the skin lesion. The term "probable" indicates that while there is a suspicion of basal cell carcinoma, there has not been definitive diagnostic confirmation.

In coding practice, it's crucial to represent only what has been definitively documented in the medical record according to the guidelines. Coding as basal cell carcinoma implies that a definitive diagnosis has been made, which isn't the case with the use of "probable."

Coding only the symptoms or the condition without confirmation could lead to inaccuracies in data mapping and patient records. Requesting further information from the physician, while a good practice for clarity, isn't necessary in this scenario unless the provider has indicated the need for further evaluation. Therefore, the safest approach given the terminology used is to code the skin lesion, ensuring compliance with coding guidelines and integrity in health information management.