Pathology/Lab Coding Alert

Question: What do I do when a pathology procedure that is carried out is not indicated by the ICD-9 diagnosis code given by the primary physician?

Anonymous Ohio Subscriber

Answer: This situation is not unusual for pathologists because, in many cases, it is the pathologist who ultimately makes the diagnosis. For example, a patient is brought to surgery to have colon polyps removed (ICD-9 code 211.3, benign neoplasm of the colon). During the procedure, the surgeon requests a pathology consultation and, upon discovery of a tumor, completes a segmental resection of the colon. The pathologist completes an examination of the tissue removed and charges for 88309 (colon, segmental resection for tumor) even though the original diagnosis does not indicate a tumor. The new diagnosis code would be assigned based on the pathologists findings (ICD-9 code 153.4, malignant neoplasm of the colon). Assigning the correct ICD-9 code for this scenario would include these steps:
Code for patients presenting diagnosis;
Code(s) for surgical procedure;
Code for actual pathological examination, regardless of
original diagnosis code; and
Code for actual patient diagnosis. Note that this code should
not be listed first.

Answers to this question and to You Be The Coder were provided by Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.