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I'm curious as to how to proceed with coding for what is being described as a "Large" transurethral resection of bladder tumor. No specific dimensions are given in the op note but simply described as a single large tumor. When I read the path report the gross description states "The specimen consists of one Telfa pad yielding five gray-tan soft tissue fragments measuring from 0.3 x 0.3 x 0.2 to 0.8 x 0.5 x 0.3 cm with an aggregate measuring 1.0 x 0.8 x 0.5 that are submitted in toto cassette."
So am I to assume that all of these fragments are making up this one large tumor and add them together, or am I supposed to take the largest dimension reported and code off of that? The patient's primary ins. is Medicare.
So am I to assume that all of these fragments are making up this one large tumor and add them together, or am I supposed to take the largest dimension reported and code off of that? The patient's primary ins. is Medicare.