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Thread: Lab coding clarification

  1. #1

    Question Lab coding clarification

    AAPC: Back to School
    I have been told to code by the results of the lab. That isn't right is it. We can only code symptoms or diagnosis not abnormalities etc.... need to have some documentation to back that up. any one out there that can point me the right direction please or anyone that has articles please give me the web link
    thank you
    Last edited by tracefurious; 06-18-2009 at 10:33 AM.

  2. #2


    It depends on what you are coding. We use the lab report for definitive dx of biopsies/surgical pathologies. Check to see if there is a specific policy for your employer. You can't use lab reports for lesion size.

  3. #3
    Join Date
    Apr 2007
    Columbia, MO


    No you may not code from a lab report because you are not a physician. Lab reports have not been physician interpreted yet and therefore may not be used or interpreted by coders. A path report on the other hand has a pathologist interpretation who is a physician and a coder may use this dx for coding. Look in the guidelines for coding and reporting, for this information.

  4. #4
    Join Date
    Apr 2007
    Capital Coders in Columbia, SC

    Default Lab coding clarification

    You can only code by the lab results when the lab result in question was interpreted by a physician, such as a pathologist. For example, you could not code urinary tract infection based on a high level of bacteria found in the urine specimen. You could, however, code lung cancer based on a pathological report from the pathologist. This is because, in the latter case, you have a diagnosis given by a physician. In the former case, you would be the person interpreting the lab report, which you (or any of us) are not allowed to do.

  5. #5
    Join Date
    Apr 2007
    Kokomo, IN

    Default lab coding clarification

    Your answer is found in the coding guidelines ICD-9 2009 Physician page 25, section L. Since lab reports are not signed by a physician and are not interpreted by physicians, you cannot code from them. The Dr. reads the lab report and makes a definitive diagnosis or you can only code signs/symptoms and reasons for the tests if there isn't a dx that can be used. You can, however, code from pathology reports for outpatient services, since pathologists are physicians.

  6. #6
    Join Date
    Apr 2007
    Bangor, Maine


    I know that this is a very old post but I was searching for information about coding paths and I was wondering if someone could help me with this:

    Now, I know that you can code a pathology report because the pathologist is a physician and s/he has interpreted it, but my question is: when it is a cancer diagnosis, does that change anything? Can you code a cancer dx without the primary physician who ordered the test documenting anything in the chart?

    Also, if the case was an ultrasound-guided biopsy and not a surgery or excision, can you still code by the path report? I thought I remembered from somewhere that you can't code path reports from biopsies, only excisions when there is a path report involved.

    Any clarification would be helpful. Thanks

  7. #7


    Can you clarify the tests the primary ordered, if the patient comes in and say by the way I need these tests there there needs to be an order somewhere in the chart from the requesting MD. OR check to see if there is a letter asking that the primary orders these tests every 3-6 months. I have worked in a small community and the patients may live several hundred miles from their specialist so the primary takes over the ordering of the labs for the patient's convinence. The specialist writes a letter to primary reqeusting what and often something may need to drawn.

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