Wiki Dx'ing after path results

[reinelt]

I have aways heard that it is ok to wait for the pathology reports to come back showing if there is cancer or not before I code it. If the path said malignant, I would code it so. I had also heard that I had to code by reason of the visit up to that point. Meaning, if it was a lesion, I should code it as 238.2 (for example). The Medicare LCD (North Carolina) says 11400-11446 that we can not way for the path reports to come in, we have to code at the highest level of dx known at the time of service.

Which is correct, code for the time of service or wait until the path results come back?

 

[FTessaBartels]

Wait for Path

I was taught to always wait for path before coding.

F Tessa Bartels, CPC, CEMC

 

[Anna Weaver]

path reports

I was also taught to wait for path reports, and I do. I code nothing until I get that report.

 

[magnolia1]

As an Ambulatory Surgery coder, the guidelines are you code diagnosis to the highest specificity (which means waiting for the Path report in situations that warrant it--biopsy being one of them)

 

[sagar_supercool]

whenever u coding for such case wait till u get the path of excised tissue.
if this comes malignant then u will have different cpt and icd.
if this comes benign then u will have different cpt and icd.
so if u code report without path this may result in fatal error in ur coding.
And also if it has been mentioned in the op report that the patient have biopsy proven malignant neoplasm or benign neoplams. Then u can code directly without waiting for path.