lots os Q & A here...be sure to read it all!
ICD-9 CODING CLINIC, Vol 20 No 4, 4th Qtr 2003
"Codes should never be assigned based solely on laboratory values."
ICD-9 CODING CLINIC, Vol 21 No 1, 1st Qtr 2004 you will find specific reference to using the radiology REPORT and how it can be used:
"Coders are confused as to why using the PATHOLOGY REPORT for greater coding specificity is different from coding the specific site of a fracture as documented on an x-ray REPORT as published in CODING CLINIC, First Quarter 1999, page 5.
In the example published in CODING CLINIC, First Quarter 1999, page 5, the physician had already documented the femoral fracture. Additional detail regarding the specific site on the femur (i.e., shaft) was being picked up from the x-ray REPORT. There is a difference in coding the documented clinical diagnosis from the attending physician and coding unconfirmed findings. When coding strictly from the PATHOLOGY REPORT, the coder is assigning a diagnosis based on the PATHological findings alone without the attending physicianâ€™s corroboration.'
ICD-9 CODING CLINIC, Vol 16 No 1, 1st Qtr 1999
A patient comes into the hospital with a fracture of the femur. Upon discharge, the physician lists in his final diagnostic statement, fracture of femur. However, when reviewing the medical record, the x-ray REPORT states that the site of fracture is the shaft of the femur. Is it appropriate to use the x-ray results to provide further specificity to this diagnosis for coding purposes?
Assign code 821.01, Fracture of other and unspecified parts of femur, Shaft. Coders should always review the entire medical record to ensure complete and accurate coding. If the physician does not list the specific site of the fracture, but there is an x-ray REPORT in the medical record that does, it is appropriate for the coder to assign the more specific code without obtaining concurrence from the physician. However, if there is any question as to the appropriate diagnosis, the coder should consult with the physician before assigning a diagnosis code."
Per ICD-9 guidelines you can use the chart to get information regarding appropriate coding.
"A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and REPORTing of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses and procedures that are to be REPORTed. The importance of consistent, complete documentation in the MEDICAL RECORD cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated."
ICD-9 CODING CLINIC Vol 23 No 1, 1st Qtr 2006
"When coding a diagnosis documented as a MASS of a particular site and that site is not listed under the main term â€śMASS,â€ť is it appropriate to look under the term â€śLESION,â€ť and if not found under â€śLESIONâ€ť should we refer to the site in the Table of Neoplasms?
It is incorrect to select a code from the neoplasm table when only the terms â€śMASSâ€ť or â€śLESIONâ€ť are used. The coder should follow the cross-references under the main term representing the documented diagnosis. If a final diagnosis is documented as â€ślumpâ€ť and there is no index entry for the affected organ or site under â€ślumpâ€ť in the index, look up the main term â€śMASS,â€ť as directed by the â€śsee alsoâ€ť note under the main term â€ślump.â€ť If there is no index entry for the specific site under â€śMASS,â€ť look up the main term â€śdisease.â€ť The index directs you to see Disease of specified organ or site for â€śMASS, specified organ NEC.â€ť
If a final diagnosis is documented as â€śLESIONâ€ť and there is no index entry for the specified organ or site under the main term â€śLESION,â€ť look up the main term â€śDisease.â€ť The index directs you to see Disease by site for â€śLESION, organ or site NEC.â€ť
ICD-9 CODING CLINIC, Vol 1 No 3, Sep-Oct 1984
"What information should coders review in the medical record to ensure that all diagnoses affecting the admission are documented? History and physical exam, discharge summary, operative REPORT, PATHOLOGY REPORT, diagnostic test results, medication records, and physician progress notes should be considered."
ICD-9 CODING CLINIC, Vol 7 No 1, 1st Qtr 1990
"Question: A patient has come back for a routine check of her mastectomy site, three years status-post her original operation. After a suspicious lump was biopsied, it was found that the cancer had reoccurred. How should this be coded?
Answer: Code to the level of specificity known for each visit. The first visit would have been coded to V71.1, Observation for the suspected malignant neoplasm, as the physician is following up a patient known to have had cancer previously. A secondary code for that visit would have been V10.3, Personal history of malignant neoplasm, Breast. After the biopsy REPORT has been received and the patient comes back for consultation, code the results of the PATHOLOGY REPORT."
ICD-9 CODING CLINIC, Vol 17 No 1, 1st Qtr 2000
A skin lesion of the cheek is surgically removed and submitted to the PATHologist for analysis. The surgeon writes on the PATHOLOGY order, â€śskin lesion.â€ť The PATHOLOGY REPORT comes back with the diagnosis of â€śbasal cell carcinoma.â€ť A laboratory-billing consultant is recommending that the ordering physicianâ€™s diagnosis be REPORTed instead of the final diagnosis obtained by the PATHologist. Also, an insurance carrier is also suggesting this case be coded to â€ťskin lesionâ€ť since the surgeon did not know the nature of the lesion at the time the tissue was sent to PATHOLOGY. Which code should the PATHologist use to REPORT his claim?
The PATHologist is a physician and if a diagnosis is made it can be coded. It is appropriate for the PATHologist to code what is known at the time of code assignment. For example, if the PATHologist has made a diagnosis of basal cell carcinoma, assign code 173.3, Other malignant neoplasm of skin, skin of other and unspecified parts of face. If the PATHologist had not come up with a definitive diagnosis, it would be appropriate to code the reason why the specimen was submitted, in this instance, the skin lesion of the cheek.
A patient undergoes outpatient surgery for removal of a breast mass. The pre- and post-operative diagnosis is REPORTed as â€śbreast mass.â€ť The PATHological diagnosis is fibroadenoma. How should the hospital outpatient coder code this? Previous CODING CLINIC advice has precluded us from assigning codes on the basis of laboratory findings. Does the same advice apply to PATHological REPORTs?
Previously published advice has warned against coding from laboratory results alone, without physician interpretation. However, the PATHologist is a physician and the PATHOLOGY REPORT serves as the PATHologistâ€™s interpretation and a microscopic confirmatory REPORT regarding the morphology of the tissue excised. Therefore, a PATHOLOGY REPORT provides greater specificity. Assign code 217, Benign neoplasm of breast, for the fibroadenoma of the breast. It is appropriate for coders to code based on the physician documentation available at the time of code assignment."
ICD-9 CODING CLINIC, Vol 19 No 2, 2nd Qtr 2002
A patient is admitted to the hospital where she undergoes a hysterectomy for possible endometriosis. The PATHOLOGY REPORT revealed adenocarcinoma of the endometrium. The discharge summary was not available at the time of coding. Is it appropriate for the coder to assign a diagnosis code for the adenocarcinoma based on the PATHOLOGY REPORT?
As previously stated, the advice published in CODING CLINIC, First Quarter 2000, was only intended for coding and REPORTing for outpatient services, where physician documentation is sometimes quite limited. It does not apply to inpatient coding. For inpatient coding, if the attending physician does not confirm the PATHological findings, query the attending physician regarding the clinical significance of the findings and request that appropriate documentation be provided. Refer to the Official Guidelines for Coding and REPORTing, Section lll B, Abnormal Findings, for additional information."
Regarding CPT codes:
CPTÂ® Assistant May 1996 Volume 6 Issue 5
"When the morphology of a lesion is ambigous, choosing the correct CPT procedure code relates to the manner in which the lesion was approached rather than the final pathologic diagnosis, since the CPT code should reflect the knowledge, skill, time, and effort that the physician invested in the excision of the lesion. Therefore, an ambiguous but low suspicion lesion might be excised with minimal surrounding grossly normal skin/soft tissue margins, as for a benign lesion (codes 11400 - 11446), whereas an ambiguous but moderate-to-high suspicion lesion would be excised with moderate to wide surrounding grossly normal skin/soft tissue margins, as for a malignant lesion (codes 11600 - 11646). Thus, the CPT code that best describes the procedure as
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