Papsmear coding question

AYS12

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:confused:

Are we to code the clinical conditions/ hx listed on papsmear path report???

Example:

History/Clinical Data:
Date of last menstrual Period: n/a

Other Clincial Conditions:
Bleeding, abnormal ( Do I include in dx coding?)
Previous Pap, within normal limits.

Help!
 

Kdailey

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Seacoast-Dover NH
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The company I work for only codes the clinical information if the path report states the technical portion only was performed. Otherwise, we only code the final diagnosis provided by the pathologist since we are billing for the labwork only and not for the office visit.
 
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