Wiki "No Pathologic Diagnosis"

[katrinabgood]

I run into this a lot, and am hoping for any advice: The doctor does an EGD, and in their preliminary report, they might state, Erosive Gastritris, or similar. Then the path report says "no pathologic diagnosis." My thinking is that the specimen is sent to the pathologist for his expertise, and that is what I should code. Co-workers disagree, and say that I need to take the doctor at their word. I'm sure I'll be told to query the doctor, but if that is my only option, I'll be querying on 98% of my charts! Any expert advice for me?

 

[MAult142]

Do you have access to the doctor's reading of the path report? In our office, after the doc signs off on the path, he indicates what he wants the letter to say that goes out to the patient. Sometimes if there are discrepancies between the op note and the path report, the doc will resolve them at that point. In your example, if the path comes back normal and the doc dictates that the letter to the patient should say the results were normal, then I would code the symptoms for the EGD instead of the erosive gastritis. And if he still indicates that he wants the letter to say gastritis was found, then I would code the erosive gastritis.