Definition of Provider
Hello all,
I have a physician who is demanding he be shown official documentation that states why he has to document pathology results. He feels we should be able to code from pathology reports since the pathologist is the one looking at the slides. I tried explaining to him that we can only use documentation done by physicians who are actually caring for the patient, that the pathologist is not providing care-same as with lab results, x-ray reports, etc.
I found in ICD-9 Official Guidelines for Coding and Reporting: "...the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient's diagnosis."
BUT who determined "legally accountable". His argument being that the pathologist is the one who determines pathology.
Thanks!
Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
Sharon.cole@phn-waco.org
I have a physician who is demanding he be shown official documentation that states why he has to document pathology results. He feels we should be able to code from pathology reports since the pathologist is the one looking at the slides. I tried explaining to him that we can only use documentation done by physicians who are actually caring for the patient, that the pathologist is not providing care-same as with lab results, x-ray reports, etc.
I found in ICD-9 Official Guidelines for Coding and Reporting: "...the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient's diagnosis."
BUT who determined "legally accountable". His argument being that the pathologist is the one who determines pathology.
Thanks!
Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
Sharon.cole@phn-waco.org
Comments
Question:
The current guideline for coding abnormal findings on the pathology report leads to unnecessary physician queries and places an unnecessary burden on the coders. Could you please consider revising this guideline?
Answer:
The Central Office on ICD-9-CM has received a number of questions concerning the advice published in Coding Clinic, Second Quarter 2002, pages 17-18, and Coding Clinic, First Quarter 2004, pages 20-21. This advice stated that coders should not code findings from pathology reports on inpatient records without confirmation of the diagnosis from the attending physician. Many coders believed that pathology reports provide more specificity in facilitating proper code assignment and that querying the attending for confirmation added to the administrative burden.
The Editorial Advisory Board (EAB) for Coding Clinic thoroughly reviewed this issue and obtained input from multiple stakeholders, including clinical advisors, physician specialty groups, hospital coders, and others. After careful consideration, the EAB decided not to revise the existing guidelines for coding abnormal findings on pathology reports. As stated in the Official Guidelines for Coding and Reporting, "Abnormal findings on the pathology report are not coded and reported unless the provider indicates their clinical significance." This ensures that the documentation and the codes reported are consistent with the attending physician's interpretation since he or she is responsible for the clinical management of the case. It is the responsibility of the attending physician to gather and collate all of the findings from the consultants and other providers involved in the care of the patient. The plan of care is based on the attending's evaluation, interpretation and collation of all the findings (i.e., pathology, radiology, and laboratory results). Although the pathologist provides a written interpretation of a tissue biopsy, this is not equivalent to the attending physician's medical diagnosis based on the patient's complete clinical picture.
Dorie Douthit, RHIT,CCS
CDI Program/HIM
706-389-3364
St. Mary's Health Care System
1230 Baxter Street
Athens, Georgia 30606
But, I am sure one of our fabulous ACDIS members will....
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
I'm holding on to this reference as this way of thinking is clearly contagious
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
THANKS DORIE!!
Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
Sharon.cole@phn-waco.org