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

Comments

  • edited May 2016
    What is the manual for exactly? Seems like outpatient questions or physician billing but I may be misunderstanding?
  • edited May 2016
    Hi Charles

    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

    IMPORTANT: This communication contains information from Hays Medical Center which may be confidential and privileged. If it appears that the communication was addressed or sent to you in error, you may not use or copy this communication or any information contained therein, and you may not disclose this communication or the information contained therein to anyone else. In such circumstances, please notify me immediately by reply email or by telephone. Thank you.
  • edited May 2016
    This is referring to Outpatient Coding.

    Sharon Salinas, CCS
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    ssalinas@barlow2000.org
  • The link is referring to outpatient coding rather than inpatient coding. The Official Guidelines do not allow one to code directly from a radiology and/or a pathology report for inpatient coding.



    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002
    Fax:  415.600.1325
    Ofc:  415.600.3739
    evanspx@sutterhealth.org
  • IS THIS FOR INPATIENT OR OUTPATIENT CODING???

    THANKS!

    Juli Bovard RN CCDS
    Rapid City Regional Hospital
  • edited May 2016
    Outpatient Juli -

    Sharon Salinas, CCS
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    ssalinas@barlow2000.org
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