When both preoperative and postoperative diagnoses are available, which diagnosis should be reported?

When both preoperative and postoperative diagnoses are available, the postoperative diagnosis should be reported because it reflects the most current and definitive assessment of the patient's condition after the surgical procedure has taken place. The postoperative diagnosis provides critical information regarding the outcomes of the surgery and any updates or changes that may have occurred based on the findings during the operation. This diagnosis is vital for coding and billing purposes as it accurately captures the nature of the patient's condition once all surgical interventions have been completed.

In contrast, the preoperative diagnosis is primarily based on clinical evaluation before the procedure and may not reflect any changes or findings that were discovered during surgery. Therefore, using the postoperative diagnosis ensures that the coding is aligned with the most updated and relevant clinical information. This is essential for maintaining accurate medical records and for justifying the services rendered in the context of documentation and reimbursement.