Coding Pathology Reports

The pathology results are often finalized after the patient is discharged and we query to get those results in the record. Has any facility found another way to capture the results without a query? If the MD were to refer to the pathology report at discharge, is there a way that the results could be coded without a query? Could the attending MD sign the pathology result and Medical Records blow it back in the record? This question was asked by our leader since we have some push back from our surgeons in answering these queries.    


  • We are not aware of another solution. But I certainly wish there was one :(

    I wouldn't think simply co-signing a path note would be ok. but you probably could develop a process where the pathologist sends the path report for so-sig and then the provider looks at it, and interprets it as an addendum to the path note????

    Katy Good

  • This is certainly a common struggle among CDI.

    We found it helpful to be very careful in how we worded the query, along with provider education [explaining how diagnosis must be affirmed by a 'bedside, hands on' provider and that the attending has the final call].  The wording for some queries was awkward in the sense it seemed to be asking the attending to determine if the pathologist was right or wrong, almost a professional oversight ... rather than affirming whether the pathology dx was relevant for this patient during this stay.

    Unfortunately, can't put my fingers on the wording that was developed at the moment.

  • Pathology

    Please indicate the clinical significance of the pathology findings below:


    Provider Query Response:*


    Clinically significant

    Not clinically significant

    Unable to determine

    Other / clarification of findings (please specify)*


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


    You may answer this Query by marking the checkbox(es) above or using free text at the ( * )  if appropriate.



    On (Date) the pathologist has identified ***. Please validate this diagnosis.   


    The purpose of this query is to ensure accurate coding, severity of illness and risk of mortality compilation.  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.

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