Pathology-OP Report

jennyifer

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Hi,

A patient undergoes a thyroidectomy. Reason for px is malignancy (biopsy proven). The physcian doesnt mention anything about a specimen sent to lab for pathology in is OP note. But there is a pathology report in the MR with a different final dx. Do you code dx from pathology? Do you look into the pathology report at all since the physician didnt refer to it in his dictation?

An immediate response is greatly appreciated!!!
 
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