Wiki Coding from path report

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kimezell

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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.
 
Agree that you can never speculate on a diagnosis. You can only code for what is written in the report.

Here is how I would code the following. I code for a pathology group.

1. clinically skin, left temple lesion, shave biopsy: lichenoid actinic keratosis
88305
702.0

2.right hip, total arthroplasty: femoral head, severs degenerative joint disease
88304, 88311
715.95

3. clinically skin, right upper eyelid lesion, excision: consistant with ruptured hair follicle
88305
704.8

4. stomach,biopsies: antral and body mucosa, reactive gastropathy and minimal chronic inflammation
88305
535.40
535.10

5. endometrial biopsy: lytic endometrium
88305
This is a description of a normal finding in the endometrium. In this case, you will need to code for the signs/symptoms that necessitated the endometrial biopsy.
 
Agreed; cannot speculate. I'm with a pathology group, too.
Also, for the 88311 "decalcified" should be mentioned in the report, right? ;)
 
I as well cannot speculate. I'm with a pathology group, too. Just started as a paid intern. They are the largest Path Group in N California. They have me reviewing completed reports that have already been coded and I am checking for coding errors. From what I have been told there should be the same number of ICD codes as there are CPT codes per report. I also believe irishhawk is right, there should be the 88311 "decalcified" code. Anyone know if I am completely correct about this?
 
wigdoctor said:
From what I have been told there should be the same number of ICD codes as there are CPT codes per report. I also believe irishhawk is right, there should be the 88311 "decalcified" code. Anyone know if I am completely correct about this?
Click to expand...

# ICD codes do not need to equal # CPT codes. This seems an odd thing to be told.

And I agree, if decalcified is mentioned in the report, add 88311.
 
Path

wigdoctor said:
I as well cannot speculate. I'm with a pathology group, too. Just started as a paid intern. They are the largest Path Group in N California. They have me reviewing completed reports that have already been coded and I am checking for coding errors. From what I have been told there should be the same number of ICD codes as there are CPT codes per report. I also believe irishhawk is right, there should be the 88311 "decalcified" code. Anyone know if I am completely correct about this?
Click to expand...

If decalcified is mentioned in the path report, it should be added in addition to the CPT codes that are in the CPT section of the patients record. Make sure there is evidence that a decal was done. While you are checking the decal code, double check the other CPT codes as well for quantity and that they match up for the tests done.
 
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