Use Pathologist Findings for This Definitive Dx Code
Question: Are we as coders allowed to code from the lab results? The ordering physician puts the requisition in, we run the labs, but then there’s a hang-up when it comes to assigning a diagnosis because the provider didn’t choose the correct code, or any code at all. Then we have to reach out to receive an approved diagnosis from the physician. Since the labs are interpreted by the provider who works at the lab, are we able to code from those results without the ordering physician’s interpretation? For example, a provider ordered a vaginal swab and attached code N77.1. Since the lab results are interpreted by the lab physician, can I pull the information such as “consistent with candidiasis” from the lab report or does the ordering physician need to review the results before I can code that out? Right now, we are only coding from what the ordering physician responds with but that can take a very long time. Just wondering if there's a shorter way to go about this. AAPC Forum Participant Answer: Yes, you can code from the lab results as they are given by an expert pathologist, whom you can regard as being equivalent to the provider in these kinds of situation. For this particular result, however, you would not use N77.1 (Vaginitis, vulvitis and vulvovaginitis in diseases classified elsewhere), as there is a more specific code for you to use. Parent code B37.3- (Candidiasis of vulva and vagina) lists candidal vulvovaginitis as an inclusion term; further, N77.1 lists B37.3- as an Excludes1 code, pointing you to B37.3- as the correct code to use for the diagnosis. From there, you will have to query your pathologist, review the lab report further, or possibly even contact the provider to determine whether the condition is acute (coded to B37.31) or chronic (coded to B37.32). Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC
