Colonoscopy

When coding a colonoscopy, should you code from the operative note or should you wait for the final results and code from the pathology report?

good question...

I have often wondered that myself. For some things, like your regular run-of-the-mill polyps, 211.3 is what you'll use regardless of whether it is adenomatous, hyperplastic, etc.

However, when the doctor suspects something like cancer, I will always wait for the pathology to confirm it. You don't want to 'give' someone cancer only to find out later you were wrong. That's the type of coding error that will really cause some problems.

I think though, that you have to really trust your doctor and his/her experience to be able to make that type of judgment.