In the inpatient setting - When a patient has an inpatient surgery where a specimen was sent to pathology, Can coders use the path report to assign a diagnosis to the surgical charge?
Example: Colonoscopy for diarrhea. Path comes back as collagenous colitis.
1) Can I use the colitis Dx on the colonoscopy claim?
2) Does the surgical provider need to confirm this path dx in a written form in the medical chart?
3) Does the surgical provider need to addend the OP note with this diagnosis before I can use it?
Example: Colonoscopy for diarrhea. Path comes back as collagenous colitis.
1) Can I use the colitis Dx on the colonoscopy claim?
2) Does the surgical provider need to confirm this path dx in a written form in the medical chart?
3) Does the surgical provider need to addend the OP note with this diagnosis before I can use it?