retro pathology queries

mary.mcgrady@accuityhealthcare.com

Hi,
I was wondering if anyone had a policy on retro pathology queries. We query for documentation of pathology reports results and have run into some resistance lately. The response has been:
• “It is unethical to addend the discharge summary and add a diagnosis after the patient has been discharged.”
• “the path report wasn’t available when the patient was in house”
• “the path result doesn’t alter the hospital course”
I have pulled the AHIMA guidelines on adding addendum
1. Entering an Addendum
An addendum is another type of late entry that is used to provide additional information in conjunction with a previous entry. With this type of correction, a previous note has been made and the addendum provides additional information to address a specific situation or incident. With an addendum, additional information is provided, but would not be used to document information that was forgotten or written in error. When making an addendum --
 Document the current date and time.
 Write "addendum" and state the reason for the addendum referring back to the original entry.
 Identify any sources of information used to support the addendum.
 When writing an addendum, complete it as soon after the original note as possible.

I feel I need to be able to justify the retro documentation – any suggestions?

Thanks

Mary McGrady, MSN, RN
Associate Director Clinical Documentation Program
Department of HIM
NYU Langone Medical Center

evanspx@sutterhealth.org

The facility Medical Staff By - Laws may address how/why/ when to amend a record - in my opinion, it is not unethical to ask for the attending to review the Pathology Record and amend the record if any significant and more specific information may/should be reported resulting from this review.

It is practical to ask for the staff to review the record and amend the record for a number of reasons:

* In today's world, the staff is compelled to d/c patients in a timely manner, and often the results of the Path Report may not be available prior to d/c

* Sometimes the Path Report alone will provide required pertinent information - such as sites of metastasis and hormonal activity that may guide medical-decision making in regards to the type(s) of drugs chosen for any chemotherapy - it may also prove ATN or rejection in a transplanted kidney, as one more example. The treating staff relies upon the results of the Path to confirm diagnoses and guide future treatment choices.

* W/O referring to the Path Report, the coding and tumor board information may be incomplete in that the types of neoplasms, primary and secondary sites may not be properly coded - this can lead to poor communication among providers and quality agencies.

As per your original message, AHIMA has long-recognized the need for providers to amend a record in a compliant manner for the reasons cited above, and also for other factors.

I have attempted to attached the standard query I devised for Confirmation of Pathology Report, but it is 'too large"

I will attempt to insert the body of the query below -
********************************************************

Request for Clarification or Confirmation
Of Radiology Findings


Dear Physician/PA/NP: __________________________________________________________________ or other responsible provider:
For accurate coding and severity-of-illness compilation, this query is directed to you. When responding to this query, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.

Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not reported unless an authorized provider indicates their clinical significance.

Thank you, on behalf of Allan Pont, MD, Vice President of Medical Affairs


The Radiologist has identified on ________________ (DATE) in the __________________________ (TYPE OF EXAM)

The Diagnosis : _____________________________



Please validate this diagnosis.

CDI Specialist/Coder: _________________________________ Date:_____________ Time: _______________


Physician/PA/NP Response:

CONFIRMATION:

0 I concur with the Radiologist Findings
0 I do not concur with the Radiologist Findings
0 Cannot be determined

CLARIFICATION of findings: Please document any SPECIFIC diagnosis or pathology associated with these Radiology findings.

0 Diagnosis/Pathology: ______________________________________________

0 No clinical significance

0 Cannot be determined

Physician/PA/NP Printed Name:___________________________________________________________________

Physician/PA/NP Signature: __________________________________________ Date: __________Time:_______

evanspx@sutterhealth.org

Sorry - I meant to insert the query for Confirmation of Pathology
Results rather than Radiology Results - here is the text devised
specifically used to ask for confirmation of Pathology Results.


****************************************************

Request for Confirmation
Of Pathology Findings


Dear Physician/PA/NP:
___________________________________________________________________ or
other responsible provider:
For accurate coding and severity-of-illness compilation, this query is
directed to you. When responding to this query, please exercise your
independent professional judgment. The fact that a question is asked
does not imply that any particular answer is desired or expected.
Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic
results) are not reported unless an authorized provider indicates their
clinical significance.

Thank you, on behalf of [insert name], Vice President of Medical Affairs

The Pathologist has identified on __________ (DATE) the Diagnosis :
_____________________________





Please validate this diagnosis.

CDI Specialist/Coder: _________________________________
Date:_____________ Time: _______________


Physician/PA/NP Response:

0 I concur with the Pathology Findings

0 I do not concur with the Pathology Findings

0 Cannot be determined

0 No clinical significance:

0 Other/Clarification of
findings:____________________________________________________________
________________________________________________________________________
_______________
________________________________________________________________________
_______________

Physician/PA/NP Printed
Name:___________________________________________________________________
_

Physician/PA/NP Signature:
___________________________________________Date: __________Time:_______


******************************************************************

Paul Evans, RHIA, CCS, CCS-P, CCDS

Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org