I would like to gather input from you all about coding surgical pathology. I work with an independent pathology lab. Currently, for all the coding I do, I have access to the order requisition and in most cases I have a clear indication for the specimens received. When I need more specific information, I can get that from the provider's office or by obtaining the operative report. The later is only needed occasionally.

My manager would like for me to begin coding more of the surgical path that we get from some of our local hospitals. In these cases, I would have just the pathology report from which to code. I don't have online access to patient records.

The examples I've seen of some of these cases are challenging to code without more detailed information as to the indication for receiving the specimens. As an example, see the case I posted below.

My manager would prefer we not slow down the coding process by waiting for faxed records, yet he still wants to be as accurate as possible. I find this balance difficult if I am striving for accuracy. How do you all manage this sort of situation?

SPECIMEN:
A. Bone biopsy
B. Bone biopsy

DIAGNOSIS:
A ? left sesamoid showing acute osteomyelitis.
B ? left metatarsal head showing fibrosis, no active inflammation.

CLINICAL HISTORY:
Left foot abscess.

GROSS DESCRIPTION:
A - labeled "left sesamoid" is a tan to brown 2.5 x 1.5 x 1 cm. portion of bone (100%,bisected,decal,1).

B - labeled "post debridement left metatarsal head" are multiple tan to brown 0.7 x 0.5 x 0.2 cm. in aggregate fragments of bone (100% after decal,1). 463:sa

MICROSCOPIC DESCRIPTION:
A ? after decalcification, the submitted bone shows reactive cortical changes with fibrosis and inflammation extending into the medullary portion of the bone. This represents osteomyelitis.

The B specimen, after decalcification, shows bone and cartilage with fibrosis of the marrow cavity. No active inflammation is seen within the marrow