Wiki Uterus size

[Unicorn1]

I have an OB/GYN who states the uterus was very big and she had to take it out in 4 sections, and she knows it weighs more than 250g, but when path report comes back it states it weighes 4.5 grams. How would you code this, by path report or by doctor note?

 

[mcnaryk]

I have an OB/GYN who states the uterus was very big and she had to take it out in 4 sections, and she knows it weighs more than 250g, but when path report comes back it states it weighes 4.5 grams. How would you code this, by path report or by doctor note?

You have to go by what is documented: remember-'not documented, not done' is the golden rule of coding. That is a big discrepancy between what the doctor is saying and what the path report says: could it maybe be 4.5 lbs? I would double check with the lab, but if they don't make any changes you have to use the code for uterus less than 250g. I hope this helps!