We have a patient that came in with a gangion cyst, per office notes. The doctor scheduled surgery and per his op, he states that he removed a ganglion cyst. I never recieved a path report from the hospital so I called to check on it, and per surgery, the specimen was not sent to path. In my opinion, I feel that I cannot code removal of gangion since I don't have a path report to back me up. We will be losing money if I code as a lesion (documented size in pre op office note as 2 cm) vs ganglion. I need other opinions on this.
-
If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Wiki coding ganglion with no path
- Thread starter heathermc
- Start date
ARCPC9491
True Blue
Why do you need the path? Not everything is sent there. You should be only be coding from your physician's documentation anyway, the path report has nothing to do with it. 
mbort
True Blue
There are several ganglion codes. You do not have to have a pathology report for everything. If the doc says it was a ganglion, then you would code it as such. You do not need to know the size of the ganglion because it does not matter for the ganglion codes that exist.
Hope this helps,
Hope this helps,
In my opinion the path means everything. The doctor is not a pathologist and cannot be 100% sure on all findings. Why would I code a ganglion when in fact it could have been something else, could have been cartillage, a regular cyst...I can't fathom never waiting for a path report. In that case why do we have pathologists? LOL. I think I have answered my own question here...thanks anyway, I don't want the risk of being audited and not have sufficient evidence to back up my coding.
hthompson
Guru
If the specimen was not sent to pathology, you won't get a report
So, you might not want to wait for it
If your provider felt that it could be malig, wouldn't he have sent it out?
I only wait for the path reports on lesions that are sent out.
So, you might not want to wait for it
If your provider felt that it could be malig, wouldn't he have sent it out?
I only wait for the path reports on lesions that are sent out.
mbort
True Blue
Neither of us said to "never" wait for a pathology. What we indicated that if a speciman is not sent, then you code per the doctors decision making. If he states it was a ganglion and he did not send the speciman for pathology then I would be confident that he knew what he was talking about. Doctors do not always need someone to tell them what a speciman is (ie lipomas, ganglion, neuromas, hernias, ovarian cysts, etc). If he was not sure of the speciman, he would have sent it off to pathology to decipher what it was.
Food for thought
Food for thought
ARCPC9491
True Blue
I agree with Mary. And as in my previous post, not everything is sent to pathology. If the physician is confident in what the specimen is, that's what is documented, that is what is to be coded. If something IS sent to path, then sure, wait for the report BUT the postoperative dx code, after path, should be on the physicians report!