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coding ganglion with no path

  1. Default coding ganglion with no path
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    We have a patient that came in with a gangion cyst, per office notes. The doctor scheduled surgery and per his op, he states that he removed a ganglion cyst. I never recieved a path report from the hospital so I called to check on it, and per surgery, the specimen was not sent to path. In my opinion, I feel that I cannot code removal of gangion since I don't have a path report to back me up. We will be losing money if I code as a lesion (documented size in pre op office note as 2 cm) vs ganglion. I need other opinions on this.

  2. #2
    Why do you need the path? Not everything is sent there. You should be only be coding from your physician's documentation anyway, the path report has nothing to do with it.

  3. #3
    There are several ganglion codes. You do not have to have a pathology report for everything. If the doc says it was a ganglion, then you would code it as such. You do not need to know the size of the ganglion because it does not matter for the ganglion codes that exist.

    Hope this helps,
    Mary, CPC, CANPC, COSC

  4. Default
    In my opinion the path means everything. The doctor is not a pathologist and cannot be 100% sure on all findings. Why would I code a ganglion when in fact it could have been something else, could have been cartillage, a regular cyst...I can't fathom never waiting for a path report. In that case why do we have pathologists? LOL. I think I have answered my own question here...thanks anyway, I don't want the risk of being audited and not have sufficient evidence to back up my coding.

  5. #5
    If the specimen was not sent to pathology, you won't get a report

    So, you might not want to wait for it

    If your provider felt that it could be malig, wouldn't he have sent it out?

    I only wait for the path reports on lesions that are sent out.
    Heidi Thompson, CPC

  6. #6
    Neither of us said to "never" wait for a pathology. What we indicated that if a speciman is not sent, then you code per the doctors decision making. If he states it was a ganglion and he did not send the speciman for pathology then I would be confident that he knew what he was talking about. Doctors do not always need someone to tell them what a speciman is (ie lipomas, ganglion, neuromas, hernias, ovarian cysts, etc). If he was not sure of the speciman, he would have sent it off to pathology to decipher what it was.

    Food for thought
    Mary, CPC, CANPC, COSC

  7. #7
    I agree with Mary. And as in my previous post, not everything is sent to pathology. If the physician is confident in what the specimen is, that's what is documented, that is what is to be coded. If something IS sent to path, then sure, wait for the report BUT the postoperative dx code, after path, should be on the physicians report!

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