Wiki Uterus >250 grams documentation

[Merlin0728]

We have a provider that would like us to bill for hysterectomies based on the size documented in the path report. He does not document the size in his operative report. Does anyone know of a coding guideline that specifically states the size needs to be documented in the operative report and/or billing for size can not be taken from the path report?
Thank you for any information you can provide.

 

[catharine]

According to AHEMA and other sources I've come across, it is acceptable for coders to code from the pathology reports without the preforming physicians including it in their dictation. See below for a link I hope it helps.

Coding Tip: Diagnosis Reporting on Outpatient Records – HIAcode


https://www.hiacode.com/.../coding-tip-diagnosis-reporting-on-outpatient-rec...

 

[Merlin0728]

Thank you for your response and the Coding Tip on diagnosis reporting from path reports. Unfortunately, I don't think this applies to using sizes reported in pathology reports.

I appreciate your help!
Becky