Results 1 to 2 of 2

Dr's note vs Path report discrepancy

  1. #1
    Monmouth Ocean
    Default Dr's note vs Path report discrepancy
    Medical Coding Books
    I have been coding hospital Endoscopy reports for a year or so. I still have some questions, that I'm hoping someone can help me with. One of my doctors routinely documents that her patients all have Reflux Gastritis, Gastritis, and Duodenitis. The path report does not always agree with this. She will also document, fairly regularly, gastric ulcer, with which, again, the path report does not agree. Am I obligated to code both? Query? (I would end up querying almost every single chart of hers!)

    One more question: If the doctor documents "Acute gastritis," (535.40) and the path says "chronic inactive gastritis," (535.10) do I code both?

    Thanks in advance, for any help! This forum has been so much help to me!

  2. Default Dr.'s notes vs Path report discrepancies
    If I see a discrepancy between a Dr.'s impression and the Pathologist report, I would query the doctor before I submit a code because a wrong diagnosis code on a claim for payment could be denied when the third party payer reviews the claim.

    For example, I received an outpatient ER report to code and the doctor's impression stated, " fractured great toe" and when I looked at the radiologist's x-ray report, the radiiologist stated that there was no fracture noted, so I sent the ER record back to the doctor with a query and he changed the impression to "sprain to great toe".

    Hope this helps.

Similar Threads

  1. help with path report
    By chewri in forum Gastroenterology
    Replies: 1
    Last Post: 11-17-2017, 10:35 AM
  2. op note dx vs path report dx
    By mommacode in forum Diagnosis Coding
    Replies: 3
    Last Post: 09-28-2015, 08:26 AM
  3. Path report
    By codedog in forum Diagnosis Coding
    Replies: 1
    Last Post: 09-15-2011, 02:04 PM
  4. path report for appendectomy
    By carol52 in forum General Surgery
    Replies: 4
    Last Post: 10-28-2010, 07:27 AM
  5. operative report/path report
    By codedog in forum Outpatient Facilities
    Replies: 4
    Last Post: 04-09-2010, 07:47 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.