My team is having different opinions on how to code a cancer diagnosis on a pathology report. Heres an example:
Pathologist Specimen: Pleura, left
Final Diagnosis
Left Pleural Fluid: Adenocarcinoma
Gross Description
The specimen consists of 30 cc of turbid fluid. Smears and cell block are prepared.
Microscopic Description
Microscopic examination performed.
One team mate states we should only code the history because it doesn’t state pleural adenocarcinoma. The other states we should code it pleural cancer since that is the specimen.
What do you guys think?