# Op report vs path report - dx & cpt?



## Amber123 (Aug 30, 2018)

Hi,

I've a case where:

*Operative report* mentions Wrist volar/antebrachial fascia cyst and *H&P report* mentions "It was a source of local discomfort left wrist". The patient also has Carpal tunnel syndrome.

The surgeon made an incision for CTR procedure and then extended it proximally to gain access to the cyst (0.5 cm) which was within the antebrachial fascia, removed it and submitted to pathology. Then, he went on and released the carpal tunnel.

*Pathology report* mentions: *benign fibroadipose tissue*

Now, since the path report doesn't mention cyst or any other abnormal finding (let alone tumor) I'm not sure what I should code for Dx and CPT. I've narrowed it down to the following:

*1. Dx - pain wrist left; CPT - Biopsy, soft tissue of wrist; deep
2. Dx - other disease fascia; CPT - Excision, tumor, soft tissue wrist, subfascial; less than 3 cm*

I'm more inclined towards the first option as there is no abnormal pathology.

Could anybody help me on this?

Thanks!

Amber


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## thomas7331 (Aug 31, 2018)

Drawing the conclusion from the pathology report that there is no abnormality or tumor is a clinical judgment - as a coder I would not make this assumption as that is making an interpretation of the results and outside of scope.  As I see it, your options are to code correctly from the documented diagnosis stated by the physician on the operative report or on the pathology report (or query the physician for clarification if you feel there is a conflict) but you cannot make a determination about which one should take priority or cancel the other out.  So if coding the surgeon's services and without additional information, I believe the second option is more correct since it more accurately reflects what was documented.  In order to justify option 1, you would be making an inappropriate assumption that the pathology invalidates both the diagnostic and procedural information that the surgeon has documented.


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## Amber123 (Sep 8, 2018)

thomas7331 said:


> Drawing the conclusion from the pathology report that there is no abnormality or tumor is a clinical judgment - as a coder I would not make this assumption as that is making an interpretation of the results and outside of scope.  As I see it, your options are to code correctly from the documented diagnosis stated by the physician on the operative report or on the pathology report (or query the physician for clarification if you feel there is a conflict) but you cannot make a determination about which one should take priority or cancel the other out.  So if coding the surgeon's services and without additional information, I believe the second option is more correct since it more accurately reflects what was documented.  In order to justify option 1, you would be making an inappropriate assumption that the pathology invalidates both the diagnostic and procedural information that the surgeon has documented.



Thank you for the response Thomas 

Your response is logical. Actually, I'm confused because if the surgeon excises a tumor and pathology report confirms it as benign or malignant, it's then coded (both ICD-10-CM and CPT Codes) depending on the final diagnosis from the pathology report. Similarly, I thought that in the aforementioned scenario if the pathologist stated the tissue as benign or normal it would be coded as normal rather than as a lesion. 

Could you shed more light on this and correct me?

Thanks!


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## cgaston (Sep 10, 2018)

Biopsies are _planned_ procedures performed for the sole purpose of removing a sample of tissue for pathological analysis.  Since this removal was not performed for that reason the biopsy code would not apply.

The surgeon removed benign adipose tissue. The "bone cyst/benign tumor" codes are closest to what is being performed in this situation so that is why this is the best code to choose.


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## Amber123 (Sep 11, 2018)

cgaston said:


> Biopsies are _planned_ procedures performed for the sole purpose of removing a sample of tissue for pathological analysis.  Since this removal was not performed for that reason the biopsy code would not apply.
> 
> The surgeon removed benign adipose tissue. The "bone cyst/benign tumor" codes are closest to what is being performed in this situation so that is why this is the best code to choose.



Thank you for sharing Carol . So, the "purpose" is key here. If the purpose is to remove sample just for pathological analysis, then, biopsy code would apply otherwise not.


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