Wiki Diagnosis from Op Report or Path?

[mlangford]

As a coder for physician surgery services, I was instructed to select the diagnosis from the pre/post surgery listed on the operative report. In the past, the diagnosis was supposed to be chosen from the pathology, if available to have the most specific diagnosis. Has there been a change in how the diagnosis should be selected? Is there a difference between how the hospital and the physician should assign the diagnosis? I would welcome comments from other surgery coders.

 

[danachock]

Coding Pathology

If you are coding pathology for your facility you are coding for your pathologist off the pathology report. Your pathologist is a doctor. You are able to take the final diagnosis off the pathology report and code it.
When a specimen is submitted to the pathology department for review the physician submitting it provides a few pieces of information - brief description of what it is and the a diagnosis code(s) for why it is being submitted and maybe a few other things like clinical notes, etc.

If you are coding inpatient and want to code off the pathology report - you may not code the anything from the pathology report UNLESS the physician has signed off or provided a diagnosis for the results of that pathology.

I dislike coding unspecified ~ especially when the specimen is left at the pathology department with something vague like "skin". At this point I always try to take the few extra moments to review the operative/procedure report when needed to further review the details of where the specimen was taken from for me to code it as accurately as I can.

Whenever in doubt about anything be sure to contact your pathology department - I have a great working relationship with my pathology department that I work with daily and also for the pathology department that I assist when needed.

Dana Chock CPC, CCA, CANPC, CHONC
Anesthesia, Pathology, & Laboratory Coder
2013 & 2014 AAPC Brainerd Chapter President