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Coding from Pathology Report

michelleholt

Networker
Messages
26
Location
Syracuse
Best answers
0
This is a two part question: First Question: When coding for a PCP, the doctor would remove a lesion in the office. We would hold that note till pathology report came back, then code the note. Is this the proper thing to do or do we code what is true that day, and code when the patient comes back for the results from the path. report?
Second Question: In orthopedics, when a patient has an infection due to surgery, has an I&D performed, the surgical coders code a T code. Now the T codes ask for an additional code to code the infection. The surgeon won't know what the infection is till the path. report comes back. Now does the coder code the T code without the additional code for the infection (which is true on that day) or does the coder wait till the path. report comes back and code the T code with the additional code for the B code for the infection.

Thank you for your answer or answers ahead of time.

Michelle Holt-Jarmacz, CPC, CPC-I
 

mitchellde

True Blue
Messages
13,538
Location
Columbia, MO
Best answers
2
This is a two part question: First Question: When coding for a PCP, the doctor would remove a lesion in the office. We would hold that note till pathology report came back, then code the note. Is this the proper thing to do or do we code what is true that day, and code when the patient comes back for the results from the path. report?
Second Question: In orthopedics, when a patient has an infection due to surgery, has an I&D performed, the surgical coders code a T code. Now the T codes ask for an additional code to code the infection. The surgeon won't know what the infection is till the path. report comes back. Now does the coder code the T code without the additional code for the infection (which is true on that day) or does the coder wait till the path. report comes back and code the T code with the additional code for the B code for the infection.

Thank you for your answer or answers ahead of time.

Michelle Holt-Jarmacz, CPC, CPC-I
For lesion excisions you must wait for the path report before you can code and submit the claim, so code from the path result.
For the infection you can code an infection without the organsim, however I think it is better to wait for the report and add the organism.
 

ehanna

Guru
Messages
149
Best answers
0
This is a two part question: First Question: When coding for a PCP, the doctor would remove a lesion in the office. We would hold that note till pathology report came back, then code the note. Is this the proper thing to do or do we code what is true that day, and code when the patient comes back for the results from the path. report?
Second Question: In orthopedics, when a patient has an infection due to surgery, has an I&D performed, the surgical coders code a T code. Now the T codes ask for an additional code to code the infection. The surgeon won't know what the infection is till the path. report comes back. Now does the coder code the T code without the additional code for the infection (which is true on that day) or does the coder wait till the path. report comes back and code the T code with the additional code for the B code for the infection.

Thank you for your answer or answers ahead of time.

Michelle Holt-Jarmacz, CPC, CPC-I
To answer part one of your question. If you are doing a removal you would need the pathology report to know if it was benign or malignant as the excision codes are different for each scenario. I hope this helps :)
 

michelleholt

Networker
Messages
26
Location
Syracuse
Best answers
0
Thank you so much for your replies.
Do you know of any Guideline that states to wait for the path. reports? Does the provider make an addendum to his note if the path. report takes a couple of days or more to get the results?

thanks again. :)
 

mitchellde

True Blue
Messages
13,538
Location
Columbia, MO
Best answers
2
There is no need in the provider setting to wait for an addendum to the office note nor is one needed to be made. You have the path report which has a diagnosis rendered by a physician, the coder may code from the result on the report.
 
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