Pathology Report Findings

elizabeth.hynd

Hi,

I would like to know if anyone has a creative way of getting surgeons to document pathology findings. We have some that are wonderful about including the findings and staging. We have others that say- get it from the pathologist, he's a physician too. Yes we have shared the coding guidelines, that tell us we cannot code from pathology reports. I did find one query an the ACDIS website in the Forms and Tools Library, but was wondering if anyone had a success story, poster, or suggestion to share.

Thanks

Beth

Elizabeth Hynd RN, BSN, CPUR
Clinical Documentation Specialist
863-687-1100 ext. 7313

katysuegood@gmail.com

Just a query....

Hope someone else has more to offer

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

dvitalone1

Can we use the words "I agree" & "I disagree" as a response on a query form?

carmella.gay

I would, but I would also add the option of "unable to determine"

Thanks, Carmella

Unknown

I believe the provider must document a diagnosis.


Charlene

elizabeth.hynd

The query on ACDIS website actually states "I concur" and "I do not concur," which is similar. The AHIMA breif says no yes or no questions except POA, it does sound like were in the same neighborhood, one house over maybe. Food for thought.

Elizabeth Hynd RN, BSN, CPUR
Clinical Documentation Specialist
863-687-1100 ext. 7313

katysuegood@gmail.com

I think it's up for debate. If I remember correctly, I adapted ours from one in an ACDIS article. That doesn't necessarily mean it's perfect, but it's what we have at the moment.

I just realized I gave you the unedited version though. Not a big change, but I removed the yes/no.

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

elizabeth.hynd

That is something we include in every query.

Elizabeth Hynd RN, BSN, CPUR
Clinical Documentation Specialist
863-687-1100 ext. 7313

evanspx@sutterhealth.org

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