Wiki Coder dilemma

[Linda Poulos]

Im having a coder dilemma: my supervisor told me to code from the procedure report on any lower GI procedures even if a path report exists. I DONT AGREE. We are to code to the highest level of specificity. I have issues with the providers impression that the pt has sessile polyps does the resection then states in the report AWAIT PATH RESULTS. I would not code the polyp when the path report clearly states that the tissue is NOT polypoid and is either a fold or mucosal tissue with lymphoid aggregates. Supervisor says that per the AGE......GI is the only specialty that allows this kind of coding. Thank you. Linda P

 

[tjrice]

T. Rice CPC, CPMA

I'm looking for guidance to present to Cardiology providers that addresses the use of 'History of', for describing ongoing, progressive, co-morbidities such as A-Fib, CKD, COPD, etc. I'm having difficulty convincing them that this term will disallow the use of the diagnosis associated with, 'History of' for MDM and risk.

 

[CatchTheWind]

Linda, maybe you would get a better response if you post this question in the gastro forum. Since your supervisor is claiming that the rule is specific to gastro, the other gastro coders should know if this is correct. (I never heard of coding rules being different for one speciality, by the way, so I am skeptical of your supervisor's claim!)

T Rice, I think I understand your basic issue (the doctors are using "history of xxx" when xxx is still active) but I don't understand what you mean by "this term will disallow the use of the diagnosis associated with, 'History of' for MDM and risk."