Diagnosis from radiology

katysuegood@gmail.com

We frequently have difficulty getting Dr's to carry over dx from radiology/pathology/etc.
Is it appropriate to format a query in a way that asks if they agree with the radiologists dx? What format do you use?
I was thinking something like:

The radiologists report states that this patient has "cerebral edema"

can you note whether you agree with this diagnosis being a medically significant diagnosis for this patient?



Any wording suggestions? Is this "leading"?

Thanks in advance!

Unknown

I often query on the clinical significance of radiology reports. An example may be:

"Could you render your opinion on the clinical significance of the CT scan report of 'cerebral edema'" and the following clinical indicators ________?

Include clinical indicators (dec LOC, trouble with speech, stroke, brain injury, neuro checks etc) that the patient exhibits or has to build your query.

Charlene

cstukenberg

I have placed the radiology impression in my note and asked if there are any significant diagnoses or conditions from the above information.

evanspx@sutterhealth.org

Below is a sample query to consider - Thanks to Lynne Spryszak [lspryszak@hcpro.com]for her review and suggestions.


Dear MD/PA/NP: _____________________________ or other responsible provider:

For accurate coding and severity-of-illness compilation, this query is directed to you. 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.

Thank you, on behalf of [insert name], Vice President of Medical Affairs


Please indicate the clinical significance, acuity, etiology, and severity of the findings (if any) noted in the Radiology Report. The documentation per the Radiology (MRI) of the medical record on 9/14/11 is as follows: “Cerebral Edema and Hernia of the Brain”.

“Do you concur with these findings identified by the Radiologist? Per Compliance Guidelines, the Attending Physician must validate the clinical significance of any diagnoses identified by the radiologist in his/her progress notes and discharge summary.

The H&P documents the patient presented with cerebral hemorrhage due to aneurysm and now is noted to have altered mental exam, ataxia, and N&V. Treatment includes Decadron and Hypertonic Saline

CDI Specialist/Coder: _________________________________ Date:_____________ Time: _______________




Paul Evans, RHIA, CCS, CCS-D

katysuegood@gmail.com

Thanks Paul! That's great!

Is it ok for the Dr to simply agree with the DR or does he also need to state WHY the dx is significant?

I was hoping to just have check boxes at the bottom with agree/disagree/unable to determine options and then a space for additional information. Is that sufficient?

Thanks again, Katy

evanspx@sutterhealth.org

If the attending concurs with a firm condition stated in the body of the Rad Exam (Edema of Brain), and answers the query in such a way that it is clear the Edema is indeed present, my opinion would be that the conditon (edema) should be coded IF it meets the UHDDS Definition of a Reportable Condition..see Coding Guidelines.

If the Radiogist notes an abnormal finding (significant shift of the brain), but does not record something that can be coded (edema of the brain), the Attending would need to describe clearly what may be inferred by the 'significant midline shift'....comment on the findings and clearly state a diagnosis.
I believe a query for Radiolgy Findings is particularly difficult and complex and we should proceed carefully with our query language to ensure we do not 'introduce' diagnostic language not present prior to our query that may only be inferred by the Rad Finding(s).