New rules for coding from pathology and radiology?
Are there new rules for coding from pathology and radiology or am I misunderstanding?
Revision date 9/10/13
Please see this link page 14 and the answer to questions 1, 2 & 3:
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104C23.pdf
The pathologist is a physician and if a diagnosis is made it can be coded. It is appropriate for the pathologist to code what is known at the time of code assignment. For example, if the pathologist has made a diagnosis of basal cell carcinoma, assign code 173.3, Other malignant neoplasm of skin, skin of other and unspecified parts of face.
The radiologist is a physician and he/she diagnosed the nephrolithiasis. Therefore, it is appropriate to code this case as 592.0, Calculus of kidney based on the radiologist’s diagnosis.
Previously published advice has warned against coding from laboratory results alone, without physician interpretation. However, the pathologist is a physician and the pathology report serves as the pathologist’s interpretation and a microscopic confirmatory report regarding the morphology of the tissue excised. Therefore, a pathology report provides greater specificity.
Charlie Morell
Revision date 9/10/13
Please see this link page 14 and the answer to questions 1, 2 & 3:
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104C23.pdf
The pathologist is a physician and if a diagnosis is made it can be coded. It is appropriate for the pathologist to code what is known at the time of code assignment. For example, if the pathologist has made a diagnosis of basal cell carcinoma, assign code 173.3, Other malignant neoplasm of skin, skin of other and unspecified parts of face.
The radiologist is a physician and he/she diagnosed the nephrolithiasis. Therefore, it is appropriate to code this case as 592.0, Calculus of kidney based on the radiologist’s diagnosis.
Previously published advice has warned against coding from laboratory results alone, without physician interpretation. However, the pathologist is a physician and the pathology report serves as the pathologist’s interpretation and a microscopic confirmatory report regarding the morphology of the tissue excised. Therefore, a pathology report provides greater specificity.
Charlie Morell
Comments
These questions are related to diagnostic testing (Outpt) and not INPT coding. It would not be appropriate in the IP setting to code without the physician caring for the patient to document the diagnosis which is on path or x-ray.
Jolene File,RHIT,CCS,CPC-H,CCDS
Documentation Improvement Specialist-Coder
Hays Medical Center
jolene.file@haysmed.com
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Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
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THANKS!
Juli Bovard RN CCDS
Rapid City Regional Hospital
Sharon Salinas, CCS
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
ssalinas@barlow2000.org