Wiki op note dx vs path report dx

[mommacode]

On EGD report the doc performs biopsies of stomach and he states patient has antral gastritis but path report states reactive gastropathy, do you only code from the path or code both?

 

[mitchellde]

The path report is the definitive dx so use that, do not code both.

 

[mommacode]

ok, that is what I do but someone told me otherwise and I wanted to clarify. If the colonoscopy op note states colon polyps were removed but the path does not show polyps then what? Don't code polyps even thought doctor stated they are polyps and polypectomy was performed?

 

[mitchellde]

What does the path state? You can use V71 codes as first listed only to show suspected condition not found when the path does not support the suspicion.

 

[Amber123]

What does the path state? You can use V71 codes as first listed only to show suspected condition not found when the path does not support the suspicion.

Hi,

I've a case where the encounter is for screening colonoscopy (ICD-10-CM: Z12.11). The surgeon found a polyp (ICD-10-CM: K63.5) in the transverse colon and excised it using snare (CPT 45385). Pathology report comes a few days later and states the excised tissue as "normal colonic mucosa".

Did the surgeon excised normal tissue only and if that is the case what would be the codes? Should we code for biopsy only and not snare since there was no lesion that was excised and was rather normal tissue?

I've narrowed it down to:

1. ICD-10-CM: Z12.11, K63.5; CPT: 45385; OR
2. ICD-10-CM: Z12.11; CPT: 45380

Any insights?

Thanks!

Amber