DX Quandry

Coastal Coders
Best answers
I find myself between a rock and a hard place.
I have in the past coded pain management, general practice, ent and a few other things.
Now I am coding anesthesia.
Here is my problem: The person I am responsible to is instructing me to code from a schedule and not from a op report.
Let's say an op report reflects Hx of polyps as a pre-dx and the post-dx is diverticulosis but the schedule says the post-dx is hemorrhoids. Now hemorrhoids does not appear anywhere in the 3 page op report, only on the schedule. I am being instructed to code the hemorrhoids from the schedule as the post op dx.
It's really bothering me. Am I wrong?
Everything I have learned thus far preparing for the CPMA exam is telling me that coding from anything other than an op report is a slippery slope.
Please Help.:(


True Blue
Columbia, MO
Best answers
You would never code anything that is not documented. The schedule is not part of the documentation and someone could have inserted the wrong dx on a schedule. The op note is what the physician renders as the dx at the time of the procedure. If the patient did not have hemorrhoids, you cannot give them to him/her. If the dx of diverticulosis leads to further testing and treatment, it may not be approved because you do not code it initially.