Wiki Bladder tumor measurements

[Calva611]

Hello I am need some advice about bladder tumor measurements when the Doctor and pathology report differ. My physician wants to bill out for a 5cm tumor but the pathology report doesn't even measure 1 cm. The physician stands by his measuring. I am trying to look for guidelines on this but coming up short. Long story short he wants to bill out a 52240 and I suggested a 52234. Who is correct? The Doctor or the pathology report?

 

[ckkohler]

I have been taught to go with the physician’s documentation. If his dictated, signed note states 5 cm then go with that. They can also use the terms “small”, “medium” or “large”. The only time I use the path report for measurements is if the size is not indicated. The specimen will always shrink or be smaller at the lab than initially measured in the OR. Now, could the shrinkage be that much? I don’t know...maybe the entire tissue didn’t get submitted? Hope this helps.