Wiki lab coding question

[KathyCastle]

Question for any lab/histopathology folks out there-when coding for example a breast bx, which shows benign tissue but in the history it says she has recently been diagnosed with ca in the other breast. Code the path results first then the ca dx?? Thank you for any input!!

 

[lngast]

I would code breast mass/cyst and then code personal history of breast cancer

 

[KathyCastle]

but it's a recent dx in the other breast-would you still use the history of code?

 

[whaleheadking]

I would just code the findings for the specimen received. Without direct evidence of the breast cancer on the slides, coding the clinical information for something that we haven't seen isn't relevent to the services the pathologist is providing.