Wiki Coding from Pathology Reports

[philwjp]

Our docs are suggesting we use their final dx on the op report and not wait for the path. This is a general rule of thumb, correct? Should we always wait for the path before coding a claim? Sometimes we are doing the 2nd surgery for margins on a skin cancer patient and the margins are benign even though the initial lesion was cancer. Our physician wants us to use the initial cancer dx for both. I don't believe this is correct coding. any thoughts?

 

[mitchellde]

If the original path report was a malignancy with positive margins, this means there is the probability that cancerous cells were left behind as the excision was not wide enough. The provider then does a re-excision to obtain a result of negative margin on the re-excised sample. but the path is looking only at the margins, the assumption being that you have excised residual malignancy left behind from the original excision. Therefore it is appropriate to code the re-excision as malignant providing the original path was malignant.