Wiki Dr's note vs Path report discrepancy

[katrinabgood]

I have been coding hospital Endoscopy reports for a year or so. I still have some questions, that I'm hoping someone can help me with. One of my doctors routinely documents that her patients all have Reflux Gastritis, Gastritis, and Duodenitis. The path report does not always agree with this. She will also document, fairly regularly, gastric ulcer, with which, again, the path report does not agree. Am I obligated to code both? Query? (I would end up querying almost every single chart of hers!)

One more question: If the doctor documents "Acute gastritis," (535.40) and the path says "chronic inactive gastritis," (535.10) do I code both?

Thanks in advance, for any help! This forum has been so much help to me!

 

[TonyaMichelle]

Dr.'s notes vs Path report discrepancies

If I see a discrepancy between a Dr.'s impression and the Pathologist report, I would query the doctor before I submit a code because a wrong diagnosis code on a claim for payment could be denied when the third party payer reviews the claim.

For example, I received an outpatient ER report to code and the doctor's impression stated, " fractured great toe" and when I looked at the radiologist's x-ray report, the radiiologist stated that there was no fracture noted, so I sent the ER record back to the doctor with a query and he changed the impression to "sprain to great toe".

Hope this helps.