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Op report vs path report - dx & cpt?

  1. #1
    Default Op report vs path report - dx & cpt?
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    Hi,

    I've a case where:

    Operative report mentions Wrist volar/antebrachial fascia cyst and H&P report mentions "It was a source of local discomfort left wrist". The patient also has Carpal tunnel syndrome.

    The surgeon made an incision for CTR procedure and then extended it proximally to gain access to the cyst (0.5 cm) which was within the antebrachial fascia, removed it and submitted to pathology. Then, he went on and released the carpal tunnel.

    Pathology report mentions: benign fibroadipose tissue

    Now, since the path report doesn't mention cyst or any other abnormal finding (let alone tumor) I'm not sure what I should code for Dx and CPT. I've narrowed it down to the following:

    1. Dx - pain wrist left; CPT - Biopsy, soft tissue of wrist; deep
    2. Dx - other disease fascia; CPT - Excision, tumor, soft tissue wrist, subfascial; less than 3 cm


    I'm more inclined towards the first option as there is no abnormal pathology.

    Could anybody help me on this?

    Thanks!

    Amber

  2. #2
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    Drawing the conclusion from the pathology report that there is no abnormality or tumor is a clinical judgment - as a coder I would not make this assumption as that is making an interpretation of the results and outside of scope. As I see it, your options are to code correctly from the documented diagnosis stated by the physician on the operative report or on the pathology report (or query the physician for clarification if you feel there is a conflict) but you cannot make a determination about which one should take priority or cancel the other out. So if coding the surgeon's services and without additional information, I believe the second option is more correct since it more accurately reflects what was documented. In order to justify option 1, you would be making an inappropriate assumption that the pathology invalidates both the diagnostic and procedural information that the surgeon has documented.
    Last edited by thomas7331; 08-31-2018 at 07:04 AM.
    Thomas Field, CPC, CEMC

  3. #3
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    Quote Originally Posted by thomas7331 View Post
    Drawing the conclusion from the pathology report that there is no abnormality or tumor is a clinical judgment - as a coder I would not make this assumption as that is making an interpretation of the results and outside of scope. As I see it, your options are to code correctly from the documented diagnosis stated by the physician on the operative report or on the pathology report (or query the physician for clarification if you feel there is a conflict) but you cannot make a determination about which one should take priority or cancel the other out. So if coding the surgeon's services and without additional information, I believe the second option is more correct since it more accurately reflects what was documented. In order to justify option 1, you would be making an inappropriate assumption that the pathology invalidates both the diagnostic and procedural information that the surgeon has documented.
    Thank you for the response Thomas

    Your response is logical. Actually, I'm confused because if the surgeon excises a tumor and pathology report confirms it as benign or malignant, it's then coded (both ICD-10-CM and CPT Codes) depending on the final diagnosis from the pathology report. Similarly, I thought that in the aforementioned scenario if the pathologist stated the tissue as benign or normal it would be coded as normal rather than as a lesion.

    Could you shed more light on this and correct me?

    Thanks!

  4. #4
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    Biopsies are planned procedures performed for the sole purpose of removing a sample of tissue for pathological analysis. Since this removal was not performed for that reason the biopsy code would not apply.

    The surgeon removed benign adipose tissue. The "bone cyst/benign tumor" codes are closest to what is being performed in this situation so that is why this is the best code to choose.
    Carol Gaston CPC CRC CPCO

  5. #5
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    Quote Originally Posted by cgaston View Post
    Biopsies are planned procedures performed for the sole purpose of removing a sample of tissue for pathological analysis. Since this removal was not performed for that reason the biopsy code would not apply.

    The surgeon removed benign adipose tissue. The "bone cyst/benign tumor" codes are closest to what is being performed in this situation so that is why this is the best code to choose.
    Thank you for sharing Carol . So, the "purpose" is key here. If the purpose is to remove sample just for pathological analysis, then, biopsy code would apply otherwise not.

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