# When do YOU code from a path report?



## fhromeo30 (Nov 17, 2017)

I am looking for documentation stating when you can use the path report for diagnosis coding.  I am finding things that **hint** that you can do this but I need something documented and reference-able.  Any help or direction would be appreciated.


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## Orthocoderpgu (Nov 17, 2017)

*When do you code from path report?*

Most of the time you will use the path report when tissue is removed and a diagnosis is not established. The surgeon will remove a "lump" and send for pathology. That "lump" could be a malignant neoplasm, benign neoplasm or a benign cyst just to name a few. In these cases, there is no way for the doc to identify a specific diagnosis until the tissue is sent for pathology.

I have docs that do biopsies with knee implants because there "may" be an infection, or maybe not. But if the biopsy comes back as infected, that knee implant is coming out.

When docs remove internal fixation, frequently they see "soft" tissue which is removed and sent for pathology. Is this an issue? Who knows until the pathologist can identify it. 

These are just examples. But as you can see there are many times that a surgeon does not know what he is dealing with until tissue is reviewed.

Anytime a doc sends something to pathology, you should not be assigning a diagnosis until that path report comes back.


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## Pam Brooks (Nov 17, 2017)

Per the AHA coding clinic, there is no requirement to wait until the pathology report before assigning a diagnosis code for outpatient (and also physician) coding.  You can code based on the providers' note alone, and actually, you can create your own policy with regards to this.  If you decide to wait for the path report, you wouldn't assign a code based on the pathology report unless your provider has seen and agrees with the pathologist's diagnosis.  We don't wait for pathology for diagnosis coding.  

Similarly in the inpatient facility, you may not code strictly from the pathology report without the attending provider having corrobrated this diagnosis.  

From a CPT perspective, you should wait for the pathology report before assigning codes for skin lesion excisions, since there are different codes for benign and malignant.  Again, make sure that the attending provider has reviewed and corroborates the diagnosis.  

And certainly, if you are coding for a pathologist, you'd code from his pathology report.


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## lillusdw (Nov 17, 2017)

I code from Pathology on my GI and any surgeries. As you can not code the procedure until you have a Path report. RMC has a great webinar 1CEU on Outpatient Diagnosis Coding: November 2017 presented  by Jennifer Jones, CCS. It is free and very good. Hope this helps.


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## Erudite (Oct 18, 2018)

*Pathology report as Global and Technical case/service type*

Hi Pam,

Will this be apply for either the Global or Technical service type? 

So, when coding a pathology final report and the type of service is Technical or Global, should the coders wait for the pathology report before assigning any diagnosis codes or are we not require to wait for the pathology report and code based on the providers’ note alone? 

Thank you in advance!
In-house lab coder
IB


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