Post discharge query
I have a physician that is refusing to answer a post discharge query. The patient had a pending path report at discharge. When the path report came back for malignancy post discharge the physician was queried. He is declining to answer the query because he states the path results were not available on discharge. I would like to show him a guideline or coding clinic that states he can write a diagnosis after discharge even though the path report was pending at discharge. Does anyone have any suggestions of guidelines or coding clinics to use?
Comments
To summarize, Paul Evans states clinical picture is not complete without this documentation. Sommer Slavin utilized her compliance department for guidance on malignancy related post-DC queries. "...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."
I tell providers the final pathology results are absolutely relevant to accurately report SOI/ROM.
Beth Watts, BSN, RN, CCDS
Clinical Documentation Improvement Quality Auditor
St. Joseph Health, NorCal
I'd add that at least sometimes the pathology report will assist others when further treatment for cancer is being considered...(precise antineoplastic therapy considered based upon pathological classification as one example). Hence, it is important to capture any metastasis and morphology.
Paul Evans, RHIA, CCDS
The Central Office on ICD-9-CM has received a number of questions concerning the advice published inCoding 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.