Wiki Coding from path report (or not)

[Leandra]

If a patient comes in for a suspicious lesion and the provider does a punch biopsy - do you code the biopsy with the diagnosis as "suspicious lesion" or do you hold until the path report comes back and bill with what the pathologist says (in this case it was malignant)? I was previously told to bill from the path report and am clarifying at this point...

 

[mitchellde]

There is no code for suspicious lesion and the guidelines will tell you that you may not code suspected dx. You may code what you know for a biopsy as a skin disorder 709.8 or you may wait for the path and code from the path if you are coding for the physician or outpatient facility. If it is an excision then you must wait for the path. If you are coding inpatient facilityhe then you may not code from the path.

 

[Leandra]

Thanks, I am coding for a physician office. In my CPC training we were told to code from the path report but I was questioned about this at work because it is "after the fact". Do you know of any documentation that states to code from the path report for this type of scenario?

 

[alambmichigan]

Leandra, I code for a multiple doctor oral surgery practice and our association, AAOMS, has always taught and stands by the practice of coding from the pathology report, due to the fact that you are dealing with a diagnosis that will stay with the patient for life.

Hope this helps,
Amy

 

[Leandra]

Thanks Amy.

 

[alambmichigan]

Your welcome Leandra. Glad I could give some assistance.

The presence of the pathology report will help clarify selection of your code, especially when you are working with benign & malignant neoplasm codes. Especially when the situation is vague at the time of the biopsy, the report helps get clarification for you on what the patient really has.

Amy