Lisa A Posted Sun 09th of October, 2016 20:13:19 PM
Postop dx: chronic cholecystis w/cholelithiasis
Pathology report: Acalculous gallbladder without significant histopathologic abnormality
Is the DX chronic cholecystis w/cholelithiasis, as this was the dx from the attending? Or only symptoms since the pathology was no abnormality
SuperCoder Answered Mon 10th of October, 2016 02:43:54 AM
Greetings from SuperCoder!
As per Coding Clinic, in an inpatient setting, coders are not able to assign codes based on the pathology report without physician confirmation of the diagnosis. For example, if the physician documents “breast lump” and the path report confirms it is breast cancer, coders cannot code “breast cancer” until the physician confirms this in the body of the record (AHA Coding Clinic for ICD-9-CM, 2008, third quarter, pages 11-12).
On the other hand, according to the CMS memo, if the results of the diagnostic test were normal or did not provide a diagnosis, the coder should report the signs and symptoms that prompted the test. The ordering physician is responsible for providing the reason for the test when it is ordered, and that information should be documented in writing in the medical record even if the test is ordered by telephone.
Please feel free to write if you have any concern/query.
Lisa A Posted Mon 10th of October, 2016 11:00:22 AM
I'm sorry. Outpatient account, where coding from path is allowed.
SuperCoder Answered Wed 12th of October, 2016 01:08:29 AM
In every case, where the results of the diagnostic test were normal or did not provide a diagnosis, the coder should report the signs and symptoms that prompted the test.