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Wiki Path Results Dx ?

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Jody Mortensen

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I need to know if anyone can tell me the guidelines to follow for reporting diagnosis codes in the following scenario: Patient had left tonsil removed & path report confirmed malignancy, the surgeon also biopsied the right tonsil in the same OR session & the report for the right was normal. Do I use dx code 146.0 for both since the right tonsil was biopsied because the left had an irregularity or do I have to list each with a different dx code, 146.0 & V76.49. I coded for a tonsillectomy & a biopsy of the right & do not see in the "Coding Companion" that V76.49 will be covered for the biopsy. Thank you in advance for your assistance.

Jody Hecht
 
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