Wiki polyp question

[Jamie Dezenzo]

Ok,
Pre/Post DX: Endometrial Polyp

Per office in op note markedly thickened endometrium and w/ 3-D rendering of the ultrasound able to see an endometrial polyp.

Patient came and had 58558 done but path comes back "proliferative endometrium and no evidence of a polyp"

The doctor was sure it was a polyp and sent curettings w/ endometrial polyp??? Sent back to doctor verify post-op dx in this case?

Thanks
Jamie

 

[btadlock1]

Ok,
Pre/Post DX: Endometrial Polyp

Per office in op note markedly thickened endometrium and w/ 3-D rendering of the ultrasound able to see an endometrial polyp.

Patient came and had 58558 done but path comes back "proliferative endometrium and no evidence of a polyp"

The doctor was sure it was a polyp and sent curettings w/ endometrial polyp??? Sent back to doctor verify post-op dx in this case?

Thanks
Jamie

The doctor should get clarification from path about their findings, since they contradict his initial judgement. Whatever he took out that looked like a polyp to him, must have been something, and the path report needs to clearly state what it was. A second opinion might be warranted, if he disagrees with their assessment.
There's always the chance that the doctor was mistaken, too - he's human, so he's allowed to be wrong every once in a while. What's important, is that he made the decision to perform the procedure, based on sound clinical judgement, and that he documented his rationale well (for malpractice purposes).

In the mean time, you can probably code this as some sort of endometrial hyperplasia (621.3X) - but you should confirm it with the doctor, first.

Hope that helps!

 

[Jamie Dezenzo]

well said and I did query the doctor to verify the path....thanks!