Query Response
Hello,
When querying the physician for a diagnosis from a pathology report, and the physician response is:
"Agree the findings are abnormal and are consistent with the possible diagnosis identified in the above pathology impression and is clinically significant."
How do you proceed? Code all findings from the path report? Or re-query for specific diagnoses? Is this acceptable to code all findings?
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Comments
Hi Doris,
In this case it would be relevant to query for specifics. If they were more definitive in their response I would be more inclined to use it but they are stating as "possible" I would add a phrase to the query template to "for clarification, please document the diagnosis in the medical record".
Thank you Deanne for your response. Much appreciated.