The AHA Central Office on ICD-10 has received many questions regarding the correct coding of outpatient laboratory, pathology, and radiology encounters and whether previously published advice in Coding Clinic for ICD-9-CM still applies. The following questions and answers are intended to assist coding professionals and staff who perform the coding function to help clarify these issues. Where feasible, previously published advice has been incorporated. This advice applies to outpatient services provided in hospital-based as well as stand-alone facilities.
A patient undergoes outpatient surgery. A skin lesion of the cheek is surgically removed and submitted to the pathologist for analysis. The surgeon writes on the pathology order, “skin lesion.” The pathology report comes back with the diagnosis of “basal cell carcinoma.” A laboratory-billing consultant is recommending that the ordering physician’s diagnosis be reported instead of the final diagnosis obtained by the pathologist. Also, an insurance carrier is also suggesting this case be coded to “skin lesion” since the surgeon did not know the nature of the lesion at the time the tissue was sent to pathology. Which code should the pathologist use to report his claim?
The pathologist is a physician and if a diagnosis is made it can be coded. It is appropriate for the pathologist to code what is known at the time of code assignment. For example, if the pathologist has made a diagnosis of basal cell carcinoma, assign code C44.319, Basal cell carcinoma of skin of other parts of face. If the pathologist had not come up with a definitive diagnosis, it would be appropriate to code the reason why the specimen was submitted, in this instance, the skin lesion of the cheek.
A patient presents to the hospital for outpatient x-rays with a diagnosis on the physician’s orders of questionable kidney stone. The abdominal x-ray reveals “bilateral nephrolithiasis with staghorn calculi.” No other documentation is available. Is it correct for the facility to report code N20.0, Calculus of kidney, based on the radiologist’s diagnosis?
It is correct for the facility to report code N20.0, Calculus of kidney. Code to the highest degree of certainty. The radiologist is a physician, and when the x-ray has been interpreted by the radiologist, code the confirmed or definitive diagnosis. The Official Guidelines for Coding and Reporting, Diagnostic Outpatient Services Section IV. K., state, “For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation.”
A patient undergoes outpatient surgery for removal of a right breast mass. The pre- and post-operative diagnosis is reported as “breast mass.” The pathological diagnosis is fibroadenoma. How should the hospital outpatient coding professional report this? Previous Coding Clinic advice has precluded us from assigning codes on the basis of laboratory findings. Does the same advice apply to pathological reports for the facility?
The facility should report code D24.1, Benign neoplasm of right breast, for the fibroadenoma of the breast.
Previously published Coding Clinic advice has warned against coding from laboratory results alone, without physician interpretation. However, the pathologist is a physician and the pathology report is confirmation of his/her tissue analysis, and can be used to provide greater specificity when coding outpatient encounters.
A referring physician sends a urine specimen to the cytology lab for analysis with a diagnosis of “hematuria” (code R31.9). However, the cytology report, which is authenticated by the pathologist, revealed bladder cancer. Although the referring physician assigned code R31.9, Hematuria, unspecified, the laboratory reported code C67.9, Malignant neoplasm of bladder, unspecified. For reporting purposes, what is the appropriate code assignment for the laboratory and the referring physician?
The laboratory should report code C67.9, Malignant neoplasm of bladder, unspecified. It is appropriate to report the carcinoma, in this instance, because the cytology report is authenticated by the pathologist, which serves as confirmation of cell type, similar to a pathology report.
The referring physician should report code R31.9, Hematuria, unspecified, if the finding of the cytological analysis is not available at the time of code assignment. If the cytology report is available, the referring physician should report code C67.9, Malignant neoplasm of bladder, unspecified.
A patient presents to the physician’s office with complaints of urinary frequency and burning. The physician ordered a urinalysis and the findings were positive for bacteria and increased white blood cells (WBCs) in the urine. Based on these findings a urine culture was ordered, which demonstrated high levels of bacteria consistent with urinary tract infection. Should the lab report the urinary tract infection, or is it more appropriate for the lab to report the signs and symptoms when submitting the claim?
Since this test does not have physician interpretation, the laboratory (independent or hospital- based) should report codes for the symptoms (i.e., urinary frequency and burning), unless the laboratory calls the physician to confirm a diagnosis of urinary tract infection.
The physician refers a patient for chest x-ray to outpatient radiology with a diagnosis of weakness and chronic myelogenous leukemia (CML). The radiology report demonstrated no acute disease and moderate hiatal hernia. For reporting purposes, which codes are appropriate for the facility to assign?
The laboratory (independent or hospital-based) should report codes for the symptoms, because a physician has not interpreted the results. Assign code R53.83, Other fatigue, unless the lab calls the physician to confirm a diagnosis of anemia.