Pathology/Lab Coding Alert

Question: Our pathologist received a uterus with a pre-op diagnosis of uterine prolapse and stress incontinence. However, the pathologist had other findings and assigned a diagnosis of mild adenomyosis, endometrial polyp, and mild cervicitis.How should we code this case?

Washington Subscriber

Answer: You should assign the diagnosis based on the pathologist's findings rather than the clinical diagnosis. That's because the -ICD-9-CM Official Guidelines for Coding and Reporting- for both inpatients and outpatients state that you should code a confirmed or definitive diagnosis provided by a physician -- in this case, a pathologist.

Instead of uterine prolapse (618.1, Uterine prolapse without mention of vaginal wall prolapse), the correct ICD-9 codes for the case are as follows:

- adenomyosis --" 617.0 (Endometriosis of uterus)

- endometrial polyp --" 621.0 (Polyp of corpus uteri)

- cervicitis --" 616.0 (Cervicitis and endocervicitis).

Because final diagnosis is not uterine prolapse, you should not report the pathology service code for prolapse: 88305 (Level IV --" Surgical pathology, gross and microscopic examination; uterus, with or without tubes and ovaries, for prolapse).

Instead, you should report the pathology service code for a uterus specimen that is not for prolapse and not for cancer: 88307 (Level V --" Surgical pathology, gross and microscopic examination; uterus, with or without tubes and ovaries, other than neoplastic/prolapse).