Coding from pathology report...


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Hello everyone,,

I started coding colonoscopies, and my consultant told me that for me to code from pathology report the physician has to make an addendum to the operative report and add the pathology findings. I thought having the pathology report was more than enough to support my billing. why would the physician add the addendum when he has his own posoperative diagnosis that reflect what he found not what the pathologist found..

Please I need and advice or a website where I can get information about this..

thank you,
Maria Booker, CPC


True Blue
Columbia, MO
Best answers
no the consultant is incorrect. Assuming these are diagnostic and not screening, you are allowed to code from the path report even thought the diagnostic report does not yet contain these findings. The report does not have to be amended to contain the path finding. As a coder for a diagnostic study you are allowed to code what is known at the time of coding from the diagnostic report or you may hold and wait for the path report and code from that. The pathologist is a physician and we code from physician diagnosis. The excepts to this are of course screenings where we code screening first listed as that is the reason for the test, and skin lesion excisions which we are required to hold and wait for the path report. But the provide does not have to amend the encounter with the path findings. The path report is good as it is.