Adding biopsy path dx to encounter

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I am trying to determine if it is acceptable for a coder to add a path biopsy dx to an encounter after the dr has reviewed and closed the report that is in the chart, as opposed to having the dr go back into the encounter and add it before billing the claim. Originally the dr only uses an unspecified dx for path ordering purposes.
 
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You can only bill what is documented. If the provider documented an unspecified DX, that's what you have to use for the encounter. Any testing and subsequent results after the encounter can't be used for the original DX/encounter as they were unknown at the time of the visit. If the provider decides to update the documentation, then you can bill whatever he/she updates the DX to.
 

mitchellde

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You can only bill what is documented. If the provider documented an unspecified DX, that's what you have to use for the encounter. Any testing and subsequent results after the encounter can't be used for the original DX/encounter as they were unknown at the time of the visit. If the provider decides to update the documentation, then you can bill whatever he/she updates the DX to.

Since the coder codes from physician render diagnosis and the pathologist is a physician, the coder may code from the path report. The provider that performed the procedure does not need to amend the note. The coder is not adding to the documentation, they are report on the claim the diagnosis rendered by a physician which was requested by the performing physician. There are several past coding clinics with regard to this.
 
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Since the coder codes from physician render diagnosis and the pathologist is a physician, the coder may code from the path report. The provider that performed the procedure does not need to amend the note. The coder is not adding to the documentation, they are report on the claim the diagnosis rendered by a physician which was requested by the performing physician. There are several past coding clinics with regard to this.

So, for example, let's say a patient sees their OBGYN for an annual exam and while the provider is doing the pap, he/she notices an abscess or lump or abnormal growth or something and decides to take a quick biopsy to send it off to be tested. The provider then documents an unspecified diagnosis for this, besides the codes for the exam, for the encounter. Are you saying it's acceptable to go back and remove the OBGYN's unspecified DX and instead use a code taken from a path report that was made after the encounter? I don't see how that would be an appropriate thing to do. Can you provide some links that discuss changing a diagnosis after an encounter to match findings that were made afterwards?

Obviously the situation would be different if you're billing the pathology charges, but I don't interpret the question posted as referring to the coding for the pathology service.
 

mitchellde

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So, for example, let's say a patient sees their OBGYN for an annual exam and while the provider is doing the pap, he/she notices an abscess or lump or abnormal growth or something and decides to take a quick biopsy to send it off to be tested. The provider then documents an unspecified diagnosis for this, besides the codes for the exam, for the encounter. Are you saying it's acceptable to go back and remove the OBGYN's unspecified DX and instead use a code taken from a path report that was made after the encounter? I don't see how that would be an appropriate thing to do. Can you provide some links that discuss changing a diagnosis after an encounter to match findings that were made afterwards?

Obviously the situation would be different if you're billing the pathology charges, but I don't interpret the question posted as referring to the coding for the pathology service.

There are several past coding clinics that deal with this issue. Inpatient facility coders are not allowed to code from path or radiology reports, however physician and outpatient coders are allowed to code from pathology and radiology interpretation reports. the coder does not have to wait for an addendum to the medical record. The provider signs off the note and if the coder is holding the claim to wait for path results then yes they will code the claim on the basis of the path diagnosis. they are not changing the providers diagnosis, they are using the diagnosis the provider was seeking when the specimen was submitted to pathology. there are several references you can find for this. I do not save these links as this is a basic coding principle.
 
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There are several past coding clinics that deal with this issue. Inpatient facility coders are not allowed to code from path or radiology reports, however physician and outpatient coders are allowed to code from pathology and radiology interpretation reports. the coder does not have to wait for an addendum to the medical record. The provider signs off the note and if the coder is holding the claim to wait for path results then yes they will code the claim on the basis of the path diagnosis. they are not changing the providers diagnosis, they are using the diagnosis the provider was seeking when the specimen was submitted to pathology. there are several references you can find for this. I do not save these links as this is a basic coding principle.

The question in the original post was regarding an encounter which had already been signed off on, but does not indicate anything about inpatient versus outpatient, if the claim was being held pending the path report, and so forth, so I'm not sure how any of this applies.

You may consider this a basic coding principal, but that doesn't mean everybody does. If you're referencing a source document to support a statement, providing a link to the document would be helpful for those of us who would like to read it ourselves instead of assuming what you've posted is 100% accurate. I don't understand why you always react as if it's something negative. Asking for a link is, in no way, an attack on you, it's just a simple request for a resource that others might like to keep.
 
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