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Pathology Diagnosis Coding

  1. #1
    Exclamation Pathology Diagnosis Coding
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    I have a question regarding Pathology diagnosis coding. When a specimen is sent to a pathologist for a certian reason (let's say 185-Prostate cancer) and the test comes out negative, what do you code the diagnosis?

    I have a situation where on the requisition, the clinical diagnosis was 185, but the pathological diagnosis found no malignancies. The coding rules say you must report the clinical diagnosis, but the path report says otherwise.


  2. #2
    Remember the rule, "Do not code what isn't there!" I would think you would code the final diagnosis. Which would be benign 222.2. Where is it said that you must report the clinical diagnosis? Did all of this happen the same day? Was there a previous history of prosate cancer? Don't know if this helps. I tried.

  3. #3

    I work for a pathology lab, so all I have to work with is the single diagnosis. There is nothing indicitive of a benign tumor.

  4. #4
    Wouldn't the lab report stating negative mean benign?

  5. #5
    The lab report is diagnosed as this:

    "Benign Prostatic Parenchyma." I spoke with a doctor, he said that parenchyma is another word for tissue. That's not a very definitive diagnosis of a neoplasm.

  6. #6
    That is for sure. So what did you end up doing?

  7. #7
    I suspected that I would have to contact the ordering physician, but got advice from the head pathologist. He confirmed that it shouldn't be diagnosed with 185 if the pathology report disproves that dx.

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