Wiki Coding DX Without Pathology

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medicalsec

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I have always done all of the coding for 6 general surgeons. I pick all codes E & M, CPT, ICD9'S . Most have no understanding of E & M coding. They want me to get the claims in faster, and so they do not want me to wait for the pathology reports. They give what they think it is on the Operative Report. I have tried to explain that this is not correct coding, but they do not feel that it really makes a difference since the code is in the general area and we have never been audited for such an issue. Example: Gallbladders have many codes, but they feel that I can just pick whatever code. What can I tell them to let them know that it really makes a difference? They did not feel that it will matter, and that it will never cause any problems to their practice. I am not talking about cancer issues, but I am referring to all other general surgery coding. I don't want to cause any issues for myself if we were ever audited. I was wondering if others code dx strictly from the Operative Report.

Thanks,

Dee
 
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for anything other than a skin lesion excision, you may code from what you have at the time of the surgery or wait for the study. You can code from the operative report and this is still correct coding. If the operative note does not contain enough diagnostic information to give you a code then you have no choice but to wait for the path.
 
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