Pathology/Lab Coding Alert

Question: When the surgeon sends a specimen, such as appendix, placenta, or fallopian tube, and the pathology report indicates normal tissue (no pathology), what ICD-9 code should I report? Michigan Subscriber Answer: If the pathology report is normal, you should use the ordering diagnosis -- typically a sign or symptom or other reason that prompted the procedure. Example: The surgeon submits left and right fallopian tubes from a patient who underwent a tubal ligation procedure. The pathology report shows normal fallopian tubes. Solution: You should list the diagnosis code for "normal" fallopian tubes as the reason for the procedure. ICD-9 does not provide a code for normal tissue, so you should list the condition that prompted the surgeon to remove the fallopian tubes: V25.2 (Sterilization). ICD-9 coding rules require you to report the most specific diagnosis available at the time. Here's how to do that: 1. If the pathology report [...]