tci General Surgery Coding Alert - 2018 Issue 7

ICD-10-CM: Follow Documentation, Definition, Deduction for Diagnosis Code

Wait for pathology report, if possible. When your surgeon performs a procedure that results in a cancer diagnosis, you’ll need to gather lots of medical details from the op report and the pathology report before you can code the case with precision. “Coders need to take various factors into consideration when coding neoplasms of various behaviors, such as the areas affected, primary versus secondary status, and cancer in situ,” says Lindsay Della Vella, COC, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania. Opportunity: Look at our experts’ comments on the following cases for some...

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