Wiki Postop Diagnosis code?

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ELBrock

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Hello!
The patient came in for a hysterectomy. The operative report list the diagnosis as:

Preoperative Diagnosis: Carcinoma In-Situ of Exocervix - D06.1
Postoperative Diagnosis: Same

I remember from my education that we should not code the Procedure until the Pathology Report was available. When it was, it listed the diagnosis as: "Invasive Squamous Cell Carcinoma of Ectocervix."
I queried the provider to clarify my choice of Diagnosis was correct, C53.1 (Malignant Neoplasm of Exocervix).
The provider responded that no, I should use the Pre-operative Diagnosis of Severe Cervical Dysplasia.
I informed the provider that guidelines state to code the Postoperative Diagnosis if it differed from the Preoperative Diagnosis, and since the Pathology Report gave a more extensive DX, that I would use the code supported by that.
The provider disputed this, stating the Pathology Report was not available until a week after the procedure, and so was not relevant to the service. The provider stated that the Operative Report does list the Postprocedure DX as Severe dysplasia, and I was told to use the code the provider gave and leave notes about our discussion.

Can anyone validate that my thinking is correct here, or should I only go off the Operative Report and not wait for the Pathology report? I want to avoid this type of scenario in the future, since I don't always query the providers if I feel confident in my code selection choice.

Thank you!
 
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I once had a physician brag to me that he could identify the pathology of a skin lesion 70% of the time. Meaning that he could remove a skin lesion and send it off to pathology, and agree with the pathologist 70% of the time. He was very proud of that. Not to take away anything from him as he is an excellent physician, but that means that 30% of the time he was wrong. Your dealing with something much more complex than a skin lesion.
 
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You could tell him that what he is saying is relevant for obtaining authorizations - what you THINK is happening, vs. coding of procedure - what is ACTUALLY happening.
 
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I will state in the real world (for physician coding), unless the diagnosis will change the procedure coding, I do not wait for pathology on every single surgery to bill. I do not believe it is required for physician or outpatient coding to wait for pathology report

Notable exceptions: lesion excision coding. Benign vs malignant. You really do need to wait for the pathology report to know. Same if physician just calls it a "mass"; I will wait for pathology.

In your specific example of a hysterectomy, if an omentectomy was also performed, the coding would change from 58150 to 58956 and you'd be losing out on almost 10 RVUs.

See this related thread: https://www.aapc.com/discuss/threads/when-do-you-code-from-a-path-report.153119/
 
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The pathology may not be available for a week but it is still the result of the specimen taken during the procedure he performed. It is fully relevant to the proper coding of the service he provided.

I had to come back and add - what if her diagnosis doesn't get updated to the malignancy code due to an oversight? That will lead to problems getting authorization for treatments that may be needed (fixable problems but avoidable delays).
 
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Your thinking is correct here and I also agree with the other responses posted. The provider is incorrect that the diagnosis from the pathology report is not relevant to the encounter - the specimen was obtained at the encounter you are coding and the fact that the report was completed at a later date does not mean that it should not be reported.

I'd just add that I would not have queried the provider in this situation. The provider isn't a coder and doesn't need to have any say in how you code - you assign codes your based on the documented statements in the record and you're not required to get the provider's approval for that. Really it's best (and most compliant) to query a provider only when there is missing or conflicting information in the record that prevents you from being able to assign the correct code, i.e. in cases where the provider needs to amend the record in order to correct a deficiency in order to be able to accurately code. In a case such as this where you have a pathology report from which you can all the information you need to assign a valid code, there's no need to take up the provider's time or open the door to a disagreement by asking them if they think you're correct or not.
 
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I remember that when we had a meeting with auditor , and she was asking my director if we still wait for pathology report before finalize cases ( because i coded a lung bx without waited for pathology report, and my assign dx was lung mass, and path was given dx as lung cancer , breast primary).
 
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