When a specimen is sent for pathological analysis during an inpatient stay, without confirmation from the attending, we are not allowed to code the diagnosis. In cases where the pathology report was not confirmed/read by the time the patient was discharged from our hospital, we must query the attending provider or will lose the clinical significance of that diagnosis.
Outpatient encounters have different coding guidelines. Outpatient coders can code directly from the pathology report without querying.
This excerpt from a Coding Clinic speaks to this guideline in more detail:
Year 2013, Second Quarter, Coding from the Pathology Report, pg. 24
Inpatient reimbursement is not based on charges alone, it
is a score that is based on the principal diagnosis, procedures, comorbidities and
complications. This score shifts when the principal diagnosis changes and
pathology findings are one of the most impactful drivers of this shift. Without
confirmation from the provider, this can result in decreased reimbursement,
which does not accurately compensate the hospital for the care provided. In
addition, it fails to capture the clinical significance and impacts the
patient’s severity of illness and risk of mortality score.
There are many cases where the pathology report can
result in the addition of multiple diagnoses, sometimes even metastases (when
lymph nodes are sampled, for example). Successfully capturing the key diagnoses
that were present during the patient’s encounter will ensure that the medical
record reflects the comprehensive clinical picture.
We want to capture the patient’s clinical picture as accurately as possible. Sometimes a pathology report will not provide additional clinical information. In these cases, we do not query.
A patient presents with fatigue, night
sweats and abdominal pain. A CT scan shows a mass in the right kidney
concerning for malignancy. A core bx of the right kidney is performed and the
tissue is sent to pathology. Pathology confirms right renal cell carcinoma.
The discharge summary may only state “right kidney mass.”
If the attending provider does not confirm the pathology diagnosis, we lose the
diagnosis of renal cell carcinoma and instead can only use “right kidney mass”
as a diagnosis, likely the primary diagnosis.
Here is how the two codes appear in Epic:
· N28.89 other specified disorders of kidney and ureter
·
C64.1 malignant neoplasm of right kidney, except
renal pelvis
We lose the cancer diagnosis entirely if our attending physician does not confirm the pathology diagnosis.
Your assessment and workup of the patient ultimately resulted in a tissue biopsy which confirmed a malignancy. If you agree with the pathology report, we are depending on you to confirm this in your query response.
A patient presents for a total
abdominal hysterectomy for uterine fibroids unspecified, pain and excessive
bleeding. The uterus is sent to pathology for analysis. The path report comes
back with “submucosal, intramural, subserosal uterine fibroids, adenomyosis of
the uterus, superficial endometriosis of the uterus.”
Without a query, we are only able to code the following:
· D25.9 Leiomyoma of uterus, unspecified
If we query the attending and they confirm the pathology findings, we can code the following:
· D25.0 submucous leiomyoma of uterus
· D25.1 intramural leiomyoma of uterus
· D25.2 subserosal leiomyoma of uterus
· N80.03 adenomyosis of the uterus
· N80.01 superficial endometriosis of the uterus
By confirming that pathology diagnosis, we get a more accurate clinical picture. Patients can have several discrete diagnoses that are likely contributing to their symptoms.
If you do not agree with the pathology findings, it’s your right as the attending physician to state this in your query response, and we will code accordingly.
Let’s work together to capture each patient’s unique clinical picture!
Contact Kerry Scannell, CCS, CPC, coding auditor/trainer; or Ashley Richards, RHIT, coding manager.