Wiki Diagnosis Code for Path/Labs

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LAKEENYA

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Hello,

Anyone's response will be appreciated. Can you tell me if it is inappropriate to bill path and lab with the diagnosis code that is the results of the test? I had a provider advise me that the diagnosis code should be unspecified or the presenting symptoms of the visit because the diagnosis was not confirmed at the time of the visit. However we had the results of the test when a correction to a claim was needed so it was coded with the results of the test, was this incorrect?
 
coding results

Hi LAKEENYA,
Hopefully this will help,
You cannot code the results of a laboratory test. Lets say Mr. Doe has an appointment and feeling fatigued and they do a vitamin D and the provider provider assigned "fatigue" for the diagnosis for that lab to be done. That is what you will code, even if it is abnormal.
However for pathology - you will code what Dr. Pathologist XXXX provides you. You cannot code consistent with or similar/resembles/consistent with. Be sure to look at the the entire pathology report. Don't just rely on the diagnosis line to provide the information you are looking for. Also be sure to look at the addendum(s) and comment(s). When in doubt ALWAYS reach out to your pathology team. If there is nothing wrong (no pathological abnormality noted) then you would provide the code on why the pathology was order (which could be a laboratory requisition).
I will also provide another example: let's say Dr. White assigns edema for a BNP (but the office visit clearly states they are trying to rule out heart failure) and the lab results are abnormal and the claim was denied for not meeting medical necessity. I would appeal sending in both the office visit outlining that they are trying to rule out heart failure with the abnormal results.
Hopefully some of the suggestions mentioned with help,
Thanks,
Dana Chock, CPC, CCA, CANPC, CHONC, CPMA, CPB
Anesthesia, Pathology, and Laboratory Coder
 
Diagnosis coding for lab report

Lab reports are clinical tests, so the reason for ordering is going to be the first listed diagnosis. If an interpretation is provided by the pathologist, coding for that will be secondary -- but it still needs to be present, for "complete" coding.
 
Hi Dana, I am curious if it is considered appropriate for a laboratory to add additional ICD10 codes to a claim based on the results of testing. A good example would be a patient sees their OB/GYN for an HPV test Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings, which works fine for the E/M service, but not necessarily for the lab test. The test comes back positive for the presence of High Risk HPV type 16 or 18, is it appropriate for the lab to add codes R87.810 or R87.811? Or should the lab request that the ordering physician add these codes to the order retroactively based on the test results in a secondary position?
 
Clinical lab coding diagnosis

For pap smears if the referring physician reports Z01.419 as the reason for the pap, however when reviewing the pap report and medical notes, the patient was pregnant and the encounter was for pregnancy test confirmation, is that Z01.419 correct if not, since payment is made via Clinical Lab Fee is the pathologist responsible for correcting this code when he renders his diagnosis and is signing out the case. I was told that the pathologist is not responsible for the validity of the referring md diagnosis since he is paid under clinical lab fee . He only renders his dx

I am inclined to disagree since both codes are going out on a claim under his provider number. I need clarity

Thanks
 
HPV Positive

ctokach said:
Hi Dana, I am curious if it is considered appropriate for a laboratory to add additional ICD10 codes to a claim based on the results of testing. A good example would be a patient sees their OB/GYN for an HPV test Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings, which works fine for the E/M service, but not necessarily for the lab test. The test comes back positive for the presence of High Risk HPV type 16 or 18, is it appropriate for the lab to add codes R87.810 or R87.811? Or should the lab request that the ordering physician add these codes to the order retroactively based on the test results in a secondary position?
Click to expand...

Hi ctokach,
An HPV that comes back positive will be R87.810 from cervix. Or otherwise if vaginal.
Its positive (abnormal) it would be wrong to code the reason why it was done.
Thanks,
Dana
 
A coder cannot code from a lab report. This includes coding abnormal lab. A lab report requires physician interpretation before the provider interpret can be coded. A path report contains a physician rendered diagnosis in the path interpretation and a coder may code the result from the path report. Once you have the diagnosis you do not cide the symptoms that are an integral part of the diagnosis.
 
Pathology Coding Question

When examining fallopian tubes for sterilization and the surgeon also submits the entire fimbriated end for examination, can we bill more than a 88302? When the surgeon submits the entire fimbriated end for examination – so more time is involved in the examination. Is that taken into consideration when coding these types of fallopian tubes?

Thank you.
 
csanchez6 said:
When examining fallopian tubes for sterilization and the surgeon also submits the entire fimbriated end for examination, can we bill more than a 88302? When the surgeon submits the entire fimbriated end for examination – so more time is involved in the examination. Is that taken into consideration when coding these types of fallopian tubes?

Thank you.
Click to expand...

Its the highest level you can bill since its a part of the fallopian tube and its relates to sterilization. The surgical pathology codes are pretty set in stone and not up to interpretation.
 
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