AHA Coding Clinic® for ICD-9 - 2010 Issue 2; Ask the Editor

Use of Cancer Staging Form for Code Assignment

The patient was admitted for heminephrectomy due to bilateral renal masses. Pathologic analysis confirmed renal cell carcinoma. The provider listed "bilateral renal masses," in the final diagnostic statement since the pathological results were not available at the time. However, the cancer staging form that the provider has completed and signed is available in the health record. Our medical staff leadership has deemed this confirmation of the pathologic diagnosis of renal cancer and sufficient documentation for coding. Is the completed and signed cancer staging form appropriate documentation for coding and reporting purposes? ...

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