Coding for Path & Lab - CCO Student Q&A Webinar #055
Pathology Reports
Coding Clinic has clearly stated that in an inpatient setting, coders are not able to assign codes based on the pathology report without physician confirmation of the diagnosis. For example, breast cancer is documented, and the pathology shows mets to lymph nodes. Coders are not allowed to pick up a code for the lymph node mets until confirmed by the physician. In addition, if the physician documents “breast lump” and the pathology confirms it is breast cancer, coders cannot code “breast cancer” until the physician confirms this in the body of the record. In this example, the pathology is not providing specificity to an already confirmed diagnosis—it was providing a separate diagnosis, breast lump vs. breast cancer (AHA Coding Clinic for ICD-9-CM, 2008, third quarter, pages 11-12).
Laboratory Results
Additional diagnoses should not be arbitrarily added on the basis of an abnormal laboratory finding alone. To make a diagnosis on the basis of a single lab value or abnormal diagnostic finding is risky and carries the possibility of error. The physician must diagnose the patient.
A value reported either lower or higher than the normal range does not necessarily indicate a disorder. Many factors may influence the value of a lab study. These include the method used to obtain the sample (eg, a constricting tourniquet left in place for more than one minute prior to collecting the sample will cause an elevated hematocrit and potassium level), the collection device, the method used to transport the sample to the lab, the calibration of the machine that reads the values, and the condition of the patient. An example is a patient who, because of dehydration, may show an elevated hemoglobin level due to increased blood viscosity.
It is the physician’s responsibility to document the patient’s diagnoses. In the inpatient setting, a diagnosis based on an abnormal laboratory result or diagnostic test should not be determined by someone other than a physician. The physician must document the diagnosis in the medical record before it can be coded. In addition, it is not adequate for a physician to use only arrows (↑ or ↓) to indicate a diagnosis, even if treatment was given for that condition. For example, the physician documents in the progress notes, “↓Na. Decrease fluid intake. Change IV fluids.” In this example, hyponatremia could not be coded without the physician documenting “hyponatremia.” Query the physician regarding the patient’s specific diagnosis. In other words, it is not acceptable to code a diagnosis based on the physician’s up or down arrows or lab values. The physician must document the actual diagnosis (AHA Coding Clinic for ICD-9-CM, 2011, first quarter, pages 17-18).
In outpatient coding, coders are allowed to code from the pathology and radiology reports without the attending/treating physician confirming the diagnosis. The pathologist and radiologist are physicians and as long as they have interpreted the tissue or test then it may be coded. Coders should code to the highest degree of certainty at the time of coding. If there is a final report available at the time of coding, which is authenticated by a physician, it may be used to code from.
Outpatient coders may not code from laboratory reports unless the physician has made a notation regarding the findings with a diagnosis from the laboratory results.
Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the physician indicates their clinical significance. "There can be a bone of contention here because technically, radiologists and pathologists are physicians.
Diagnosis Reporting on Outpatient Records
In outpatient coding, coders are allowed to code from the pathology and radiology reports without the treating physician confirming the diagnosis.
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| Field | Range | Field | Range |
|---|---|---|---|
| Organ or Disease-oriented Panels | 80047 – 80076 | Drug Testing | 80100 – 80104 |
| Therapeutic Drug Assays | 80150 – 80299 | Evocative/ Suppression testing | 80400 – 80440 |
| Consultations (Clinical Pathology) | 80500 – 80502 | Urinalysis | 81000 – 81099 |
| Molecular Pathology | 81200 – 81479 | Multianalyte Assays with Algorithmic Analyses | 81500 – 81599 |
| Chemistry | 82000 – 84999 | Hematology and Coagulation | 85002 – 85999 |
| Immunology | 86000 – 86849 | Tranfusion Medicine | 86850 – 86999 |
| Microbiology | 87001 – 87999 | Anatomic Pathology | 88000 – 88099 |
| Cytopathology | 88104 – 88199 | Cytogenic Studies | 88230 – 88299 |
| Surgical Pathology | 88300 – 88399 | In Vivo Laboratory Procedures | 88720 – 88749 |
| Other Procedures | 89049 – 89240 | Reproductive Medicine Procedures | 89250 – 89398 |
There are two types of general tests in Path and Lab: qualitative and quantitative. Quantitative tests how much of a certain thing is in the body (say, calcium or alcohol), while qualitative tests for the presence of a substance, period.
Path and Lab codes are measured by the number of tests performed, and not the results of the test.