Coding from pathology report

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Coding from pathology report

Postby pedscoder » Wed Apr 26, 2017 1:59 pm

Good morning!

In what circumstances is it appropriate to code from the pathology report? My surgeons dictate and sign their operative note before the pathology diagnosis comes back, so oftentimes the postoperative diagnosis is vague such as "abdominal mass".

I've read that Coding Clinic states that in an inpatient setting, coders are not able to assign codes based on the pathology report without physician confirmation of the diagnosis. Is this true for facility AND professional physician coding?

Thank you!
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Re: Coding from pathology report

Postby bill.wong » Thu Apr 27, 2017 5:10 pm

This is an older CMS Transmittal AB-01-144, but it does allows the coder to code from the Pathology Report, based on the Q & A at the bottom. I don't recall this changing in ICD-10.

Here is the excerpt:
Question 3:
A patient undergoes outpatient surgery for removal of a breast mass. The pre- and post-operative diagnosis is reported as “breast mass.” 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?

Answer 3:
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 pathologist’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.
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Re: Coding from pathology report

Postby pedscoder » Tue Jan 02, 2018 7:48 pm


The CMS question specifically states, "how should the Hospital Outpatient Coder code this?" I am trying to find a definitive answer for Pro-fee coders. If a surgeon removes a breast mass and his pre/post op diagnosis states "breast mass", but the pathologist documents "fibroadenoma", can the pro-fee coder code fibroadenoma as the principle diagnosis to CPT 19120?

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