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agolder

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When coding from a surgical report... if the surgeon gives a diagnosis (such as diverticulosis) but does not specify the location, yet the location is documented in the procedure section of the report (ie large intestine), can it still be coded to that location? Or should it be coded as unspecified location, since the surgeon did not specify that location as part of the diagnosis?
 
In my mind, if I can justify my decision using the note then I will choose something more specific than the stated pre/post op diagnosis.

For example, if the provider indicates that a colonoscopy was performed for "diverticulosis" but he states in his report "scattered diverticula found throughout the sigmoid" I would code diverticulosis of the large intestine instead of unspecified. I have written documentation of the location even though he just states "diverticulosis" in the pre/post op diagnosis on his note.
 
Excellent! That's what I thought, but I feared for a moment that I may be overstepping. Thanks for sharing your expertise!
 
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