retro pathology queries

mary.mcgrady@accuityhealthcare.commary.mcgrady@accuityhealthcare.com
in CDI Talk Archive
Hi,
I was wondering if anyone had a policy on retro pathology queries. We query for documentation of pathology reports results and have run into some resistance lately. The response has been:
• “It is unethical to addend the discharge summary and add a diagnosis after the patient has been discharged.”
• “the path report wasn’t available when the patient was in house”
• “the path result doesn’t alter the hospital course”
I have pulled the AHIMA guidelines on adding addendum
1. Entering an Addendum
An addendum is another type of late entry that is used to provide additional information in conjunction with a previous entry. With this type of correction, a previous note has been made and the addendum provides additional information to address a specific situation or incident. With an addendum, additional information is provided, but would not be used to document information that was forgotten or written in error. When making an addendum --
 Document the current date and time.
 Write "addendum" and state the reason for the addendum referring back to the original entry.
 Identify any sources of information used to support the addendum.
 When writing an addendum, complete it as soon after the original note as possible.

I feel I need to be able to justify the retro documentation – any suggestions?

Thanks

Mary McGrady, MSN, RN
Associate Director Clinical Documentation Program
Department of HIM
NYU Langone Medical Center

Comments

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    The facility Medical Staff By - Laws may address how/why/ when to amend a record - in my opinion, it is not unethical to ask for the attending to review the Pathology Record and amend the record if any significant and more specific information may/should be reported resulting from this review.

    It is practical to ask for the staff to review the record and amend the record for a number of reasons:

    * In today's world, the staff is compelled to d/c patients in a timely manner, and often the results of the Path Report may not be available prior to d/c

    * Sometimes the Path Report alone will provide required pertinent information - such as sites of metastasis and hormonal activity that may guide medical-decision making in regards to the type(s) of drugs chosen for any chemotherapy - it may also prove ATN or rejection in a transplanted kidney, as one more example. The treating staff relies upon the results of the Path to confirm diagnoses and guide future treatment choices.

    * W/O referring to the Path Report, the coding and tumor board information may be incomplete in that the types of neoplasms, primary and secondary sites may not be properly coded - this can lead to poor communication among providers and quality agencies.

    As per your original message, AHIMA has long-recognized the need for providers to amend a record in a compliant manner for the reasons cited above, and also for other factors.

    I have attempted to attached the standard query I devised for Confirmation of Pathology Report, but it is 'too large"

    I will attempt to insert the body of the query below -
    ********************************************************

    Request for Clarification or Confirmation
    Of Radiology Findings


    Dear Physician/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.

    Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not reported unless an authorized provider indicates their clinical significance.

    Thank you, on behalf of Allan Pont, MD, Vice President of Medical Affairs


    The Radiologist has identified on ________________ (DATE) in the __________________________ (TYPE OF EXAM)

    The Diagnosis : _____________________________



    Please validate this diagnosis.

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


    Physician/PA/NP Response:

    CONFIRMATION:

    0 I concur with the Radiologist Findings
    0 I do not concur with the Radiologist Findings
    0 Cannot be determined

    CLARIFICATION of findings: Please document any SPECIFIC diagnosis or pathology associated with these Radiology findings.

    0 Diagnosis/Pathology: ______________________________________________

    0 No clinical significance

    0 Cannot be determined

    Physician/PA/NP Printed Name:___________________________________________________________________

    Physician/PA/NP Signature: __________________________________________ Date: __________Time:_______
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Sorry - I meant to insert the query for Confirmation of Pathology
    Results rather than Radiology Results - here is the text devised
    specifically used to ask for confirmation of Pathology Results.


    ****************************************************

    Request for Confirmation
    Of Pathology Findings


    Dear Physician/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.
    Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic
    results) are not reported unless an authorized provider indicates their
    clinical significance.

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

    The Pathologist has identified on __________ (DATE) the Diagnosis :
    _____________________________





    Please validate this diagnosis.

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


    Physician/PA/NP Response:

    0 I concur with the Pathology Findings

    0 I do not concur with the Pathology Findings

    0 Cannot be determined

    0 No clinical significance:

    0 Other/Clarification of
    findings:____________________________________________________________
    ________________________________________________________________________
    _______________
    ________________________________________________________________________
    _______________

    Physician/PA/NP Printed
    Name:___________________________________________________________________
    _

    Physician/PA/NP Signature:
    ___________________________________________Date: __________Time:_______


    ******************************************************************

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    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

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