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ebarnett

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I have a Podiatry doctor that wants to see something in writing stating that when coding excision of a lesion(s) you should code from the pathology report. Can anyone help me with this?

Thanks
 
In the ICD-9-CM 2009 physician page 25 section L last paragraph it states:

"For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses."

This should include the pathology report as it is interpreted and signed by a physician (Pathologist). It does not indicate it should be interpreted by your physician.

Any other thoughts?
 
Not malignant without path report

Most definitely you would never use a "malignant" Dx code UNLESS you have a confirmed path report.

You do not want to give a patient a condition s/he may not actually have. This medical record will follow the patient FOREVER!

F Tessa Bartels, CPC, CPC-E/M
 
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