Hi
annettebec,
There is a little more information needed please for diagnosis assignment. What did the gross and microscopic portions state? Sometimes reviewing those areas of the pathology report is what you need for proper diagnosis assignment.
Let me just throw out a fictional pathology report from the top of my head using your information:
Final diagnosis:
First and Second Left Toe:
Ulcer, necrosis and acute and chronic inflammation
Microscopic:
Both the left hallux and the index toe have both intermediate and surface necrosis of the bone. The soft tissue and skin have necrosis and both acute and chronic inflammation throughout.
Macroscopic:
Received in Specimen bucket labeled AB-999-99999 two individual pieces of tissue with bone.
The first piece is labeled A1A is grossly necrotic measuring 5x4x3 cm and is a dusky red to black tone that is odorous
Representative samples are placed in A1A, A2A, A3A and A4A
The other piece is labeled with A2B that is also grossly necrotic and measures 6x2x2 cm and is dusky red to black tone and the bone is exposed from the tip of the specimen. A small piece from the tip was decalcified and placed in A2B and representative sections were placed in A3B, A4B, A5B, A6B, and A7B.
What did you actually bill for CPT codes? Was it all bundled under one 88305x1 kind of thing? Or did your pathologist's separately identify one specimen from the other in the Gross description to bill them separately? Does my coding scenario make sense to you on what to be looking for?
Please reach out if this didn't assist you, normally the answers I would be looking for would be in the gross and microscopic portions of the pathology report. Yes we focus on the final rendered diagnosis but sometimes the other information we may need for diagnosis code assignment may be located elsewhere.
Have a great evening and reach out if you have any questions,
Dana