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coding from path

  1. #1
    Default coding from path
    Medical Coding Books
    Quote Originally Posted by mdunn View Post
    I have been reading some of the previously posted questions regarding "coding diagnoses from the path report" and everyone seems to agree that you should always wait for the path. I have read that you should only code from reports such as path and radiology if they have been interpreted by the physician, and I have also read that the pathologist or radiologist is a physician and you may code from their reports. Which is correct? This is just one of the many things that drives me crazy about this job, "Contradictory information"!!!!
    This is unfortunately another of those gray area's in our black and white world. You can in an outpatient setting code from the pathology report. I will usually, always wait for the path report to code. The radiology report is the really gray area. Some will not code from them. It depends on what the setting is whether I will or not. I use it in the ER as confirmation. I usually don't pull from it except to confirm location etc. as in a fracture. If physician says fracture arm, I will check the radiology report to confirm exact location. I usually don't code the incidental findings in this instance, unless it's directly related. When coding radiology I do code directly from the radiology report. It is correct the radiologist and pathologist are both physicians so we can code from their reports. What confuses a lot is that we cannot code from the laboratory reports, but we can from pathologist. The laboratory reports are not signed by a physician. These tests are ran by lab techs/machines and are not interpreted at all until your physician gets them.

    Hope I didn't make it more confusing for you.

  2. #2
    Default
    Only use the diagnosis that is in the documentation, provided by the physician you are billing/coding for.

    Say a physician does a biopsy and he thinks it's a benign lesion. In his operative report, he states the pre and post op dx is a benign lesion. Most of the time on the op reports I see, the pre and post dx's are the same -- even if a specimen was sent to path.

    So then, the pathology comes back and it's actually malignant. The provider who performed the biopsy needs to state the "postoperative diagnosis is a malignant lesion"

    This should be included in the op note ... or an addendum should be made.

  3. #3
    Default path
    Quote Originally Posted by ARCPC9491 View Post
    Only use the diagnosis that is in the documentation, provided by the physician you are billing/coding for.

    Say a physician does a biopsy and he thinks it's a benign lesion. In his operative report, he states the pre and post op dx is a benign lesion. Most of the time on the op reports I see, the pre and post dx's are the same -- even if a specimen was sent to path.

    So then, the pathology comes back and it's actually malignant. The provider who performed the biopsy needs to state the "postoperative diagnosis is a malignant lesion"

    This should be included in the op note ... or an addendum should be made.
    I've never heard it has to be included in the OP note. Do you have documentation for this? I would be interested in seeing it. Thanks!

  4. #4
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    Columbia, MO
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    The guidelines for coding and reporting are really pretty clear on this. The physician and the the oupatient coder are expected to use the dx rendered in the path report and radiology reports as they are physician rendered, and labs no since they must have physician interpretation. Inpatient facility coders however are prohibited from coding from the path and radiology reports, and if the attending physician does not include the path or radiology dx in their note then the coder is to query the physician to ask if the dx is significant and then the physician will have to write an addendum for the inpatient coder to be able to include the dx. Also coding clinics have visited this issue on numerous occasions. I hope this helps.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
    Default
    I agree Debra.

    As far as a reference, I do believe it's in the official ICD9 guidelines. which should be in the front or back of your book -- or you can google it

  6. #6
    Default path coding
    Sorry, I did know you could not code for inpatient from the path, but I have always done outpatient and can, so I was confused. I didn't make it clear in my previous post that I am an outpatient coder. Thanks for the clarification.

  7. #7
    Location
    Columbia, MO
    Posts
    12,531
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    Yes you may code directly from the path even if the physician has yet to review it.

    Debra A. Mitchell, MSPH, CPC-H

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