Osteomyelitis Specification from Pathology Report

alee2020

The MD documents in the discharge summary that the pathology report indicates Osteomyelitis only without documenting Acute or Chronic. However, the pathology report indicates findings of Bone Acute Osteomyelitis. The coder requests a query for the MD to document the specificity of the Osteomyelitis before it can be coded. My question is: Can the greater specificity of the Acute Osteomyelitis on the pathology report be coded since the MD has documented Osteomyelitis without specification in the discharge summary? Or should the MD be queried to documented Acute or Chronic Osteomyelitis in the discharge summary?

rpinson@hcq1.com

The ICD-10 convention is that once a definitive diagnosis like osteomyelitis is established/documentation further detail /specificity can be assigned based on a physician-interpreted report like pathology, imaging, EKG, echo, cath report, etc.  But, you cannot code anything from reports if the provider has not established a pertinent diagnosis. See Coding Clinic First Quarter 2013 page 2 – Using X-ray report for specificity, and the 2017 CDI Pocket Guide, page 10 (Greater specificity).

Richard D. Pinson, MD, FACP, CCS
Pinson & Tang
CDI Educators and Advisers
Authors of the CDI Pocket Guide
www.pinsonandtang.com

alee2020

Thank you, Dr. Pinson