StacyTerramiggi
Networker
Hello,
I am pretty new to pathology coding and the company has me coding in the Derm Q, for the most art I find it relatively easy and cool but I have issue time to time on the correct level of service per the final diagnosis given, mainly I struggle to is it a 88305 or a 88304? I posting the report I am coding below .... here is how I am wanting to code this so maybe it will be easier to see how I am thinking on this, TY very much as I really do want to rock this position
My codes: (88304-26, x)(DX for Fibroepithelial polyp= L91.8) (DX for Nevus lipomatosis superficialis= D17.39) would I be correct to code both as a 88304? as it is mainly the Nevus lipomatosis superficialis that I am questioning?
Please and Thank you
S Terramiggi
Clinical Information:
History of skin tags over body, two on right buttock and groin larger and with
pain.
Pre-Operative Diagnosis:
Skin tag
Specimen Received:
A: Skin, excision, right buttock
B: Skin, excision, right groin
Final Pathologic Diagnosis:
A. Skin, excision, right buttock:
Nevus lipomatosis superficialis
B. Skin, excision, right groin:
Fibroepithelial polyp
The examination of this case material and the preparation of this report were
performed by the staff pathologist.
***Electronically Signed*** bb1/11/29/2017 ...... M.D.
(Pathologist)
Gross Description:
Received are 2 formalin filled containers labeled with the patient's name
"xxxxx."
Part A is additionally labeled "right buttock" and consists of a shave biopsy of
skin, 1.7 x 1.2 cm. The specimen is inked at its base, serially sectioned and
entirely submitted in cassettes A1, A2, and A3.
Part B is additionally labeled "right groin" and consists of a shave biopsy of
skin, 1.2 x 0.8 cm. The specimen is quadrisected and entirely submitted in
cassette B.
bb1/11/28/2017 Path Assistant
Microscopic Description:
The final diagnosis of each specimen incorporates the microscopic examination
findings.
I am pretty new to pathology coding and the company has me coding in the Derm Q, for the most art I find it relatively easy and cool but I have issue time to time on the correct level of service per the final diagnosis given, mainly I struggle to is it a 88305 or a 88304? I posting the report I am coding below .... here is how I am wanting to code this so maybe it will be easier to see how I am thinking on this, TY very much as I really do want to rock this position
My codes: (88304-26, x)(DX for Fibroepithelial polyp= L91.8) (DX for Nevus lipomatosis superficialis= D17.39) would I be correct to code both as a 88304? as it is mainly the Nevus lipomatosis superficialis that I am questioning?
Please and Thank you
S Terramiggi
Clinical Information:
History of skin tags over body, two on right buttock and groin larger and with
pain.
Pre-Operative Diagnosis:
Skin tag
Specimen Received:
A: Skin, excision, right buttock
B: Skin, excision, right groin
Final Pathologic Diagnosis:
A. Skin, excision, right buttock:
Nevus lipomatosis superficialis
B. Skin, excision, right groin:
Fibroepithelial polyp
The examination of this case material and the preparation of this report were
performed by the staff pathologist.
***Electronically Signed*** bb1/11/29/2017 ...... M.D.
(Pathologist)
Gross Description:
Received are 2 formalin filled containers labeled with the patient's name
"xxxxx."
Part A is additionally labeled "right buttock" and consists of a shave biopsy of
skin, 1.7 x 1.2 cm. The specimen is inked at its base, serially sectioned and
entirely submitted in cassettes A1, A2, and A3.
Part B is additionally labeled "right groin" and consists of a shave biopsy of
skin, 1.2 x 0.8 cm. The specimen is quadrisected and entirely submitted in
cassette B.
bb1/11/28/2017 Path Assistant
Microscopic Description:
The final diagnosis of each specimen incorporates the microscopic examination
findings.