Could someone please shed some light on an ongoing discussion we are having in our office. Below are some examples of diagnosis that we have on path reports. Some of us feel we should code from the path report and not speculate and add a diagnosis code that is not mentioned on the report. Others of us feel that if a biopsy code is listed (88305, 88307, 88309) that the diagnosis must contain a neoplasm code along with the diagnosis listed on path report. Some opinions on this would be very helpful.
1. clinically skin, left temple lesion, shave biopsy: lichenoid actinic keratosis
88305
2.right hip, total arthroplasty: femoral head, severs degenerative joint disease
88304, 88311
3. clinically skin, right upper eyelid lesion, excision: consistant with ruptured hair follicle
88305
4. stomach,biopsies: antral and body mucosa, reactive gastropathy and minimal chronic inflammation
88305
5. endometrial biopsy: lytic endometrium
88305
How would you code these? Thank you in advance for your time.
1. clinically skin, left temple lesion, shave biopsy: lichenoid actinic keratosis
88305
2.right hip, total arthroplasty: femoral head, severs degenerative joint disease
88304, 88311
3. clinically skin, right upper eyelid lesion, excision: consistant with ruptured hair follicle
88305
4. stomach,biopsies: antral and body mucosa, reactive gastropathy and minimal chronic inflammation
88305
5. endometrial biopsy: lytic endometrium
88305
How would you code these? Thank you in advance for your time.