Code from the content of the report, not necessarily what is listed on the "heading" often times they are wrong or misleading. A lot of times it gives you the signs and/or symptoms the patient is having ... i.e. abdominal pain suspected appendicitis/cholecystitis... and at the conclusion, postoperative diagnosis, a definitive diagnosis is given. Always code the postoperative diagnosis. Another example would be a breast biopsy... the preoperative diagnosis is say, breast mass... but upon pathology results, it's malignant... so it should be coded as breast cancer, not breast mass.
Hope that helps...
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