Question: The pathologist examined a bursa fluid aspirate smear from the left elbow, identifying reactive synovial lining cells. He also used polarizing microscopy to diagnose uric acid crystals present. What is the correct coding for this case?
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Answer: Assuming that the pathologist examined direct smears from the bursa fluid aspirate and performed light microscopy with a polarizing lens to identify the uric acid crystals, you should code the procedure as follows:
The pathologist should not assign the diagnosis code based on the uric acid findings alone. The ordering physician will take the pathology results and the clinical presentation to assign a specific code, such as 274.9 (Gout, unspecified).
Do this: Lacking a final diagnosis, the pathologist can report the ordering diagnosis as the reason for the service.