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Wiki Diagnosis coding for excisions

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randijelinek

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When coding an excision we hold for the pathology report to determine whether the lesion is begnin or malignant. We have always been adding the dx from the procedure documentation but we are wondering if it should be coded from the pathology report instead. Right now we are billing malignant excision codes with a nonmalignant dx becauset the provider didn't know the dx at the time of excision.

Does anyone have any thoughts on this and know of any supporting documentation from CMS?

Thanks,
Randi
 
You should code from the path report. It is allowed since the path report is signed by a physician and the speciment was submitted by your physician.
 
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