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.
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