Outpatient Facility Coding Alert - 2021 Issue 9
Reader Questions: Dictate Dx from Pathology Report
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Article Overview
This short Q&A article is for coders handling gastrointestinal pathology and operative documentation. It explains the general approach to resolving a discrepancy between a surgeon’s specimen description and the pathologist’s final diagnosis, and it identifies the diagnosis coding category involved.
Why This Topic Matters
Documentation discrepancies between operative and pathology reports can affect diagnosis coding accuracy and claim consistency. The article helps readers understand the documentation source hierarchy discussed in this scenario and the broader code category referenced for this type of finding.
What You Will Learn
- How a pathology final diagnosis can affect diagnosis coding selection
- What to consider when operative documentation and pathology terminology differ
- Which broad diagnosis coding category is discussed for this type of colorectal finding
- Why specificity matters in assigning a diagnosis code for a rectosigmoid lesion
Who Should Read This
- Medical coders
- Coding auditors
- Billers
- GI surgery coding staff
- Pathology coding staff
Codes Discussed
Code Ranges Discussed
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