tci General Surgery Coding Alert - 2019 Issue Q4

Reader Question: Use Path Report or History for Dx

Question: The op note states that a patient undergoing a lumpectomy has a history of DCIS. How should I code the diagnosis? Texas Subscriber Answer: Ideally, you would wait for the pathology report and code the final diagnosis for the lumpectomy. Without a final diagnosis, you’ll have to code the “ordering diagnosis” or the reason for the test. You don’t mention any other signs or symptoms from the op report, such as a perceived “lump” or an abnormal mammogram. With the information you have, you’re left with coding the personal history of ductal carcinoma...

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