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How to code a cancer diagnosis.

mgreg2009

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My team is having different opinions on how to code a cancer diagnosis on a pathology report. Heres an example:

Pathologist Specimen: Pleura, left

Final Diagnosis
Left Pleural Fluid: Adenocarcinoma

Gross Description
The specimen consists of 30 cc of turbid fluid. Smears and cell block are prepared.
Microscopic Description
Microscopic examination performed.


One team mate states we should only code the history because it doesn't state pleural adenocarcinoma. The other states we should code it pleural cancer since that is the specimen.

What do you guys think?
 
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DX: Pleural Adenocarcinoma

Hello mgreg2009,

Since the final diagnosis states adenocarcinoma, I would code this as pleural adenocarcinoma. It is not a history as the adenocarcinoma was the findings of this pathology report.

Hope this helps further clarify!

M. Hannus, CPC, CPMA, CRC
 
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