Wiki OP-notes - Postoperative diagnosis vs Findings (Practicode)

[CodingKing]

I'm finally logging into my practicode subscription on a consistent basis and practicing ICD-10-CM selection. Which section of an OP note is best to use for DX selection? Findings or Post op Diagnosis?

It seems like Practicode selects findings most often. How is it in the real world? In the latest example, Pre and Post-op diagnosis listed Parotid neoplasm. I went with Neoplasm of unspecified behavior of digestive system based on the neoplasm table, since no mention of any pathology being done (its a salivary gland). They went with H93.8X1 - Other specified disorders of right ear as the findings section mentioned "palpable mass in the right parotid gland in front of the ear just inferior to the zygomatic arch"

 

[Bindesh Pandya]

Usually, we preferred to select post op diagnosis as primary code while coding for surgery.

 

[mitchellde]

I'm finally logging into my practicode subscription on a consistent basis and practicing ICD-10-CM selection. Which section of an OP note is best to use for DX selection? Findings or Post op Diagnosis?

It seems like Practicode selects findings most often. How is it in the real world? In the latest example, Pre and Post-op diagnosis listed Parotid neoplasm. I went with Neoplasm of unspecified behavior of digestive system based on the neoplasm table, since no mention of any pathology being done (its a salivary gland). They went with H93.8X1 - Other specified disorders of right ear as the findings section mentioned "palpable mass in the right parotid gland in front of the ear just inferior to the zygomatic arch"

Neoplasm of uncertain behavior is a diagnosis that can be rendered only with a path report. And neoplasm unspecified needs the diagnosis of tumor or growth. If you look in the code book at the D49 sub section it tells you the term mass is not to be interpreted as a neoplasm.