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Wiki Surgeon vs pathologist dx

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bertll

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I have been coming across quite a few colonoscopies that the surgeon removes what he thinks is a polyp, but the path report says colonic mucosa. Do I code the polyp because that is what the surgeon thought it was?
 
I realize that, therefore my question. What do you code the "polyp" the surgeon thought was there to cover its removal?
 
polyp that isn't a polyp - answer/example provided

Hi, frequently I see these coding pathologies and without seeing the pathology report I will provide a common example provided to me.

Physician passes a specimen to the pathology department with label on specimen container "sigmoid polyp".

The pathology says something similar to this:
Received specimen, measured it, bisected it and put in containers XA, XB, and XC.

Microscopic performed.

Diagnosis: Benign colonic mucosa, no pathological abnormality.

At this point I would look to the reason for the pathology being done. Sometimes I will see "screening", other times I will see Sigmoid Polyp. At this point depending on what the reason is for the pathology being done would be my diagnosis for this pathology.

I hope this helps,

Dana Chock, CPC, CCA, CANPC, CHONC
Anesthesia, Pathology, and Laboratory Coder
 
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