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[audrey matthews]

When coding a surgical account, do you code the pathology report or the pre-op physician Dx, when they differ? Here is an example: pre-op Dx: Excision squamous cell ca. Path report is inflamation. Thanks, Audrey

 

[philgro]

I think the path report is the final say in cases like this. Where I work, if we see in the notes that biopsies have been taken, we don't even code until the path is available, since that is more definitive than the Dr.s impressions.

 

[mitchellde]

This is scant information to go by. If this is the original excision then we do not know it is a squamous cell cancer until the path report states. So my question from your information is, was this an excision performed after an initial biopsy which showed the cancer? if so you code the cancer code. Or was this an excision after an initial excision where the margins were positive so this is the re excision? if so code the cancer. OR if this is the initial excision then code based on the path report as there is no precident for the dx of the cancer as the pre op dx.