Querying providers on pathology results after the patient has been discharged - is it ethical?

I recently sent a query to one of our surgeons related to the pathologist's findings on the surgical sample he had sent from the kidney mass he had resected. The pathology results were not available before the patient was discharged and so the surgeon did not have this information during the inpatient admission. Many providers at the medical facility where I work are concerned when answering this query because they feel they are being asked to attest to something they didn't have timely (during the inpatient admission) knowledge of.

Have other providers, CDIs and coders run into this situation and what was the education you shared with the provider?  Thank you!

Judi Gill, RN, BSN, CCDS


Comments

  • The fact the nature of any neoplasm is confirmed after D.C does not present an ethical challenge.  Since these path reports are used to precisely define the nature, site, location, etc, of the mass, a query is required.  Lacking a query referring to the nature of the neoplasms, the data for the encounter may be incorrectly reported to the Tumor Registry, the CDC, and so on.  Further, the nature of the disease managed and treated by the Surgeon may not be accurate.  The fact the surgeon ‘did not have the results until after discharge’ does not negate the need for a query.   Surgeons and Oncologist WILL refer to the findings of the Pathologist as they initiate any other required treatment for cancer that may be present, such as chemotherapy, immunotherapy, and so on.  

    We use above when we discuss this with surgeons.


    Paul Evans, RHIA, CCDS
  • We have a surgeon who stated he will always agree with the path report and does not want to be queried on the findings? Stated he will sign something if he needs to, but doesn't want a query. Trying to figure out a process for this. Any suggestions? 
  • Facilities may not code directly from a pathology report.  I can’t think of a compliant work around other than a query.
  • My thought as well. 
  • Would an attestation on the Path Report by the provider be acceptable to capture the specificity?
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