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Wiki Surgery diagnosis coding

mlangford

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As a coder for physician surgery services, I was instructed to select the diagnosis from the pre/post surgery listed on the operative report. In the past, the diagnosis was supposed to be chosen from the pathology, if available to have the most specific diagnosis. Has there been a change in how the diagnosis should be selected? Is there a difference between how the hospital and the physician should assign the diagnosis? I would welcome comments from other surgery coders.
 
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