In our quality reviews, we often encounter confusion regarding how to code two SSDI fields for Prostate: Number of Cores Positive and Number of Cores Examined. This confusion typically arises when there is a discrepancy between the pathology report’s final diagnosis and the gross description, or between the dictated physician procedure report and the pathology report.
To prevent errors in coding, it is essential to prioritize the pathology report’s final diagnosis, followed by the gross description. If the pathology report is available for review, it should be used as the primary source document for coding the number of cores positive and examined, as specified in the SSDI Manual.
During this Oncology Coding Break, we will:
- Discuss the two fields in detail
- Provide clarification on the use of code X6 (positive cores, unknown how many)
- Walk through case examples, reviewing both the pathology report final diagnosis and the gross description
Join us for this session to enhance your understanding and accuracy in coding these fields.
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