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surgeons post op dx vs pathology dx

Bridget Posted Thu 31st of January, 2019 09:03:17 AM
The patient had a Hyst D&C. Post op dx per surgeon is Hypertropic endometrium with hypertrophic polyps and hypervascular polyps suspicious for neoplasm. Per the pathology report: Endometroid adenocarcinoma, FIGO 1, with squamous differentiation arising in a background of complex endometrial hyperplasia with atypia. The dx I intend to use is C54.1 endometrial cancer & N85.02 endometrial hyperplasia with atypia. My provider (surgeon) disagrees stating you cannot upcode based on the path because it wasn't known or relevant to the procedure. I am just looking for confirmation/documentation that you can code based on the pathologist final report for my provider.
SuperCoder Answered Fri 01st of February, 2019 08:07:40 AM

Hi Bridget,

 
Thanks for your question.
 
The term upcoding or downcoding is not related to ICD-10 CM codes. It is related to CPT codes since the payment is associated with CPT codes.
 
Now coming to the selection of diagnoses codes, it is always better to select the diagnoses codes based on the pathology reports since these are the confirmed diagnoses.
 

We hope this answers your question.

 

Please feel free to write if you have any question.

 

Thanks

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