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Pathology Report

Barbara Posted Thu 04th of March, 2010 16:49:36 PM

Question...do you code from the Gross Description of the pathology report or from the Microscopic Description (Pathologic Diagnosis)?

Thanks in Advance.

Nellie Answered Thu 04th of March, 2010 18:27:27 PM

I code from the final diagnosis/microscopic. Gross description/specimen submitted/history are contributing factors.

SuperCoder Answered Fri 05th of March, 2010 08:16:29 AM

I agree... Final diagnosis oi Impression is the place from where one should pick up the definitive Dx. Other comments and findings mentioned by the pathologist are for reference, not the conclusive factor.

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