Pathology reports after discharge

A few physicians have expressed concern regarding pathology queries i.e. the legalities of agreeing to path findings after the patient was discharged.

Does anyone have any insight/guideline/article  to share to ease their concerns?



  • There are no regulations that do not permit an MD to comment on the clinical significance of such reports, and all Medical Staff Bylaws make provisions for clinicians to make ‘late entry’ to a record.   To put this in perspective, if we can’t query for confirmation of significance of pathology reports, then it would follow it is ‘not ethical’ to query at all post discharge, and this is not the case.  CDI or Coding Teams will sometimes need to query after discharge as it is not always feasible to conduct all reviews concurrently.   Additionally,  Pathology Reports are often not available until after discharge, and the results often yield information that should be coded for continued care - such as confirmation of the type and behavior and staging of neoplasms.   Often, the results of said reports are used to determine if further treatment may be required and also the type of treatment, such as the drugs used to treat a Cancer.  Bottom line to me is that w/o the coding of these reports, the clinical record may be incomplete.

    Paul Evans, RHIA, CCDS
  • Our providers list pathology pending on the DCS.  Then the query sent after discharge also says, pathology was pending at discharge. -- see below wording of our query.

    Final pathology results were pending at discharge and now resulted.




     Please review and make a dated addendum to the DISCHARGE SUMMARY acknowledging post-discharge findings.

  • I don't know of any official reference to share with them but it is standard practice as many are not available until after discharge. I always tell the MD's it's one of the necessary evils to accurately portray the patient's condition. You could show them the effect of proper coding on their DRG an SOI/ROM. If you showed them a case where the final dx was "brain tumor" and path gave the specificity, etc.. Same can be done with GYN or any other specialty. 

    If they still have issues you can always run it by your legal or compliance departments and maybe if they say there's no issue then they will be ok with it. 

    I also always try to make sure they understand that the results have to be interpreted by a treating Physician and they were treating the patient at the time of the inpatient admission. 

    Keep us posted on how it goes!
  • providers can certainly amend the discharge summary to recognize the path results. I encouraged them to state- "upon receipt of final path...."  Your HIM policies should outline how an amendment is added and dated etc.
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