Re: Post discharge queries re: Pathology report docum entation
--part1_14452.7817c7b4.388112af_boundary
Content-Type: text/plain; charset="US-ASCII"
Content-Transfer-Encoding: 7bit
No, we just do not code from pathology reports or xray reports unless the
attending confirms the diagnosis. We will code all diagnoses from the
consulting physicians, attending and anesthesiologist. But for pathology and
radiology reports, we prefer the attending document also.
In a message dated 1/14/2010 7:11:28 P.M. Eastern Standard Time,
cdi_talk@hcprotalk.com writes:
So you don't code anything from consultants w/o the attending documenting
the same?
Content-Type: text/plain; charset="US-ASCII"
Content-Transfer-Encoding: 7bit
No, we just do not code from pathology reports or xray reports unless the
attending confirms the diagnosis. We will code all diagnoses from the
consulting physicians, attending and anesthesiologist. But for pathology and
radiology reports, we prefer the attending document also.
In a message dated 1/14/2010 7:11:28 P.M. Eastern Standard Time,
cdi_talk@hcprotalk.com writes:
So you don't code anything from consultants w/o the attending documenting
the same?
Comments
I think they are saying they do not code from a pathology report. The results of the path report have to be documented in the chart by the attending. At our facility we will accept the documentation from a consultant as long as it is not contradicted by the attending.
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.