AHA Coding Clinic® for ICD-9 - 2004 Issue 1; Clarifications

Abnormal Findings on Pathology Report

We have received a number of questions concerning recent advice published in Coding Clinic Second Quarter 2002, pages 17-18. The advice stated that coders should not code findings from pathology reports on inpatient records and the attending physician needs to confirm the diagnosis. Coders are confused as to why using the pathology report for greater coding specificity is different from coding the specific site of a fracture as documented on an x-ray report as published in Coding Clinic First Quarter 1999, page 5. There seems to be quite a bit of confusion as to why using the pathology report is not the same (i.e., more specific pathological diagnosis "carcinoma of the breast" versus the physician's diagnosis of "breast mass.”) Please clarify. ...

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