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?

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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 includes a definitive diagnosis, you should use that diagnosis.

2. If the pathologist hasn't reached a definitive diagnosis or the tissue is normal, you should report the signs, symptoms, or conditions that prompted the ordering physician to request the service.