Wiki Medical Coder I

[MOS]

I'm a hospital coder, all things OUTPATIENT. My question has just come up recently - can we code a final diagnosis from a Pathology report? The surgeon removes a localized skin mass from patient's hand, doesn't specify what it is. The Pathology report says epidermal inclusion cyst. Can I code the cyst or must I stay with an unlisted mass?
Thanks for your help.

 

[thomas7331]

Yes, under CMS guidelines, pathology and other diagnostic test reports that have been interpreted and documented by a physician or NPP can be used for coding for purposes of reporting the diagnosis. Lab or test results that are automated cannot be used for coding (unless a provider documents their interpretation in the chart).

 

[Venkatakrishnan]

Yes MOS. We have to code based on pathology report findings which were reviewed by the Physician since it will give the exact morphological nature of the tissue excised.

Thanks,
Vernon Kreiss