Wiki Is it ok to add the Path report Dx on Surgery ICD9 coding??

[coding2244]

Hello,
I am getting mixed message's from Co-workers about placing the results of the final Path report Dx'(s) code's on the surgery CPT code's that were done? Example a pt. is having a Craniotomy for supratentorial brain tumor (61510) with Stealth image guidance with intradural Stereotactic volumetric resection of the bran tumor (61781), use of the operating microscopoe for intradural microdissection (69990) and Intraoperative functional mapping :
Preoperative Dx : Right frontal hemorrhagic brain tumor
Postoperative Dx: Right frontal hemorrhagic brain tumorPath Report from this procedure:Brain , excision: -Glioblastoma multiforme (WHO grade IV)
Intraoperative Consultation Diagnosis: Frozen Section A1 Diagnosis: Brain tumor: Favor high-grade glioma with necrosis.

ICD9 code's used 191.1 & 431is this correct? Please help!
also does anyone know what internet link I can go to that describe's about rules and regulation's about reporting Path reports with the surgery codes??
Thank You to All my AAPC.com friends and family for reading and helping!!!

 

[camillecoder@hotmail.com]

The AHA Coding Clinic has seemed a litte unclear with its advice. In 2000 the remark was made that a pathologist is a physician, therefore, the dx from the path report may be used. In 2002 AHA "clarified" their advice saying that the advice given in 2000 was relevant for outpatient services and that for inpatient services the attending must confirm the path findings.

Section III B of the ICD Guidelines note: "Abnormal findings (labatory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the finding are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added.
Please note: This differs from the coding practices in the outpatient setting for coding encounters for diagnostic tests that have been interpreted by a provider."

Section IV L of the ICD Guidelines note: "For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation."

So it appears that it is ok to use path report for outpatient services and not ok for inpatient.

References: ICD-9 Coding Clinic, 1st Qtr, 2000. ICD-9 Coding Clinic, 2nd Qtr, 2002.

 

[mitchellde]

That is actually true as applied to the facility coder, the physician coder will go by the outpatient rules regardless of setting.

 

[coding2244]

Thank You for resolving this Question


Thank you so much for responding to my Thread! Your response has help clear up ?? in this regard!

Sincerely,

Janet

 

[karilynn]

I have this same question and the response here is not totally clear to me. I often run into where the Pathologist's result and the Surgeon's postoperative diagnosis do not match. What diagnosis is used on the surgery as the final diagnosis?

Example:

Pathology results: Cholilithiasis with chronic cholecystitis (574.10)

Surgeon postoperative diagnosis as listed on op note: Acalculous Cholecysitis (575.10)

Do you have a link for information that defines this? The AHA Coding Clinic First Quarter page 3 refers to the diagnosis used on the pathology, not the surgery.

Thanks,

Kari