Indications vs path finding

[bridgettemartin]

I am coding a rectal suction biopsy operative report. The pathology reports state there are no ganglion cells present at 2cm. I queried my provider who states this is diagnostic of Hirshsprung's. I really can't find anything in my book regarding the "lack of ganglion cells". Would you just code the indication for the biopsy?

 

[mitchellde]

Your provider is correct. look up Hirshsprungs disease.

 

[bridgettemartin]

Can I code Hirschsprung's based on path findings?

Debra, thanks for the prompt reply. I agree with the provider. I should've been more specific in my post. When I try to look up a code for "no ganglion cells" there is nothing. I am wondering if from a coding perspective, is it okay to code Hirschsprung's, when the path report just states "no ganglion cells identified"?

 

[mitchellde]

Sometimes we have the definition of the diagnosis but not the diagnosis. When you google no ganglion cells identified.. the only answer is Hirshsprungs disease.
from John Hopkins:
"The definitive diagnosis of Hirschsprung disease is made by a rectal biopsy. This procedure involves removing a small piece of tissue from the rectum. Doctors examine the tissue sample under a microscope and look for the presence of ganglion cells (nerve cells). If no nerve cells are visualized, Hirschsprung disease is diagnosed. "
I was always told that when you have the definition of the disease you can code the disease. If you are uncomfortable with that then have the provider add an addendum for the dx or code the symptoms.

 

[bridgettemartin]

Thanks! I feel okay with it, but wanted to make sure I wasn't overstepping my scope of practice.

Bridgette Martin LPN, CPC, CGIC