Pathology/Lab Coding Alert

Question: An ob-gyn submitted 3 cm sections of right and left fallopian tubes with a surgical note indicating that he removed the tissue as part of a routine sterilization procedure. Our pathologist found evidence of malignant neoplasm, however. What is the correct CPT and ICD-9 coding for this case? Illinois Subscriber Answer: You should assign the diagnosis based on the pathologist's findings rather than the surgical report. Instead of using the ICD-9 code indicating that the surgeon submitted the fallopian tubes from a sterilization procedure (V25.2, Sterilization), you should use the code that indicates your pathologist's findings. In this case, list 183.2 (Malignant neoplasm of fallopian tube). Here's why: The ICD-9-CM Official Guidelines for Coding and Reporting for both inpatients and outpatients state that you should code a confirmed or definitive diagnosis provided by a physician --in this case, the pathologist. Diagnosis affects charge: This scenario points at an important [...]