Documentation for Pathology Results post discharge

angela.clayberg@mwhc.comangela.clayberg@mwhc.com
in Clinical & Coding
Hello,

How do you handle documentation for path results post discharge? We currently send retrospective query to the attending MD on the account, however, we have some MDs who do not want to document path findings post discharge. Is this an issue for other facilities? What have you done to help get this documentation and relieve the physician concerns? Thanks

Comments

  • sommer_slavin@urmc.rochester.edusommer_slavin@urmc.rochester.edu
    edited May 2016
    We have struggled with the same issue for years. Our Compliance Department has helped us research the issue to help ensure we were capturing appropriate documentation. The ICD-10-CM Official Guidelines for Coding and Reporting (Approved by CMS, NCHS, AHA, AHIMA) are very helpful; Chptr 2 Neoplasms, Section IIA., Section IIIB. Also - the AHIMA/ACDIS Query Guidelines (February 2013) state- A query should be generated when the health record documentation is conflicting. If the attending physician documents “mass” “lump”, “nodule”, or “lesion”, and the pathologist documented “carcinoma” this would be conflicting information and would require clarification from the attending physician and the AHIMA Standards of Ethical Coding- states that coders may not “misrepresent” the patient’s clinical picture through incorrect coding or omission of diagnosis or procedure codes. If we know the patient has a definitive diagnosis on the pathology report, it would be negligent not to report that diagnosis.


    Sommer Slavin, RN, MS, MBA
    Operations Manager
    Utilization Management at Strong Memorial Hospital
    Work (585) 276-5265
    Pager  (585) 275-2222 PIC 3226



     

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    It is important to report diagnosis stated as per the pathology report, and this must often be done post-discharge. As we know, one often needs the path result to code something such as a 2ndry site of cancer...w/o such codes, the clinical picture is not complete, and we may not code directly from such results.



    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.412.9421



    evanspx@sutterhealth.org





  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Same basic workflow here, Jeff..CDI issues if path rept available concurrently, generally, takes some time and pt is d/c before results known to CDI/MD.

    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.412.9421



    evanspx@sutterhealth.org





  • arozhkovskayaarozhkovskaya
    edited May 2016
    Huge issue with some docs, especially surgeons. We asked our consultants to assist, but it still continues to be query number one that we need to involve DMA almost every time we post queries to confirm path report.

    Anna Rozhkovskaya, RHIT, CCS, CCS-P,
    Manager Clinical Documentation Improvement
    HIM, Memorial HealthCare System,
    (954)265-6974 (Cisco)
    (954-276-9957 (Office)


  • arozhkovskayaarozhkovskaya
    edited May 2016
    Our coders do not query. They will send chart to CDIS to post all queries if they need any clarification even if it was no CDIS on case and we are following these charts with providers until queries are answered.

    Anna Rozhkovskaya, RHIT, CCS, CCS-P,
    Manager Clinical Documentation Improvement
    HIM, Memorial HealthCare System,
    (954)265-6974 (Cisco)
    (954-276-9957 (Office)



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