AHA Coding Clinic® for ICD-9 - 2013 Issue 2; Ask the Editor

Coding from the Pathology Report

For inpatient cases, coders are expected to query the physician if there is conflicting information between the medical record final diagnosis and the pathology report. However, if a patient is admitted with a brain mass, the provider notes in the operative report that the tumor was removed and the pathology report contains specific information as to the type of tumor, (e.g., benign or malignant), can the more specific diagnosis (malignant tumor) be coded based on the pathology report?  ...

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