path results after discharge.

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
I am under the impression that if we get path results after a patient is discharged, those are not coded as they will not be documented in the record by the treating MD (only the pathologist). I assume that we also can not query retrospectively based on this data.
For example: Assume we have a patient with a renal mass who gets a nephrectomy and is discharged 2 days later. 2 days after discharge, path report comes back that it is "clear cell carcinoma". Can a query be placed to add that data to the medical record prior to coding?
I know this is not entirely "CDS" related because it would be a retrospective query generated by coding. However, I am being asked and I know there are Coders on this forum.

Thank you!

Katy

Comments

  • Unknown
    edited May 2016
    Our coders query all the time on paths. The results must be documented by the attending physician, not straight off the path report.

    The bill is not dropped until the path report comes in.

    I listened to a round table by 3M yesterday regarding coding neoplasms and they said query to get the path information from the attending. For example, if a patient comes in with breast cancer and the path report is negative does not mean that patient does not have cancer, could have been removed from a separate biopsy and this path report confirms clear margins. So we do not know unless the physician tells us.



    Charlene

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    You should check your local Medical Staff By-Laws and touch base with
    your HIM Leadership regarding how one may 'amend' a record after
    discharge of patient.

    In addition, the HIM and CDI Query Policy & Procedure should state one
    may query concurrently and after discharge.

    At every facility I have consulted (hundreds), one may fashion a
    post-discharge query to the MD and ask the MD to make a compliant
    'late-entry' in the record. It is reasonable to ask for a late-entry as
    the site of any metastasis and or exact type of the neoplasm was not
    known to the MD during the acute episode of care.



    Paul Evans, RHIA, CCS, CCS-P

    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    evanspx@sutterhealth.org

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Ok. Great. Thank you for the help. Since I do not generally review retrospectively, I did not know how to respond to this question. Our coders ARE currently doing this now. Apparently, we have a MD who is claiming that this should not be happening and even use the F-word (Fraud). HIM is handling the response. I was just asked as well and had no idea.

    Thanks!

    Katy Good, RN, BSN
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404

  • vanessa.falkoffvanessa.falkoff
    Path report interpretation for final diagnosis is one of our most
    frequent queries. Sometimes the residents balk at adding information to
    the chart after discharge and I show them the coding guidelines
    regarding the diagnosis "after study" being appropriate.

    Vanessa Falkoff, RN
    Clinical Documentation Coordinator
    University Medical Center of Southern Nevada
    office (702) 383-7322
    cell (702) 204-0054
    vanessa.falkoff@umcsn.com
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Thanks...it is not 'fraud' at all. The MD often will not have access
    to a Path report at all during the admission. Therefore, it is a
    must to query for many Path reports after discharge is the results add
    value to the database.



    Paul Evans, RHIA, CCS, CCS-P

    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    evanspx@sutterhealth.org

  • Unknown
    edited May 2016
    At our facilities, either the CDS or the coder is asking for an addendum to the summary providing results of the pathology.

    Linda Haynes, RHIT
    Interim CDI Manager
    Legacy Health
    Portland, Oregon
    Phone: 503-692-7498
    Pager: 503-938-0210

  • sbeattysbeatty
    If the case was one that a CDS reviewed, we handle the RQ. If it was a case that we didn't get to prior to discharge, the coder handles the RQ. Either way, one of our roles queries for the specificity prior to the final coding.
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