AHA Coding Clinic® for ICD-9 - 2006 Issue 1; Ask the Editor

Coding Metastatic Sites from Pathology Reports

Would it be appropriate to assign codes for metastatic sites based on findings in pathology reports in the inpatient setting? Previous Coding Clinic advice has stated that pathology findings fall into the category of abnormal findings. The Official Guidelines for Coding and Reporting, Section III, B. Abnormal Finding, states “Abnormal findings, (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the physician indicates their clinical significance. If the findings are outside the normal range and the physician has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the physician whether the abnormal finding should be added.” Without confirmation from the attending abnormal findings are not typically coded. ...

To read the full article, sign in and subscribe to AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS .

Thank you for choosing Find-A-Code, please Sign In to remove ads.