Pathology results need confirmation for diagnosis

Why attending physician confirmation is important

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.

Here are a few clinical scenarios:

Example #1

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.

Example #2

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

Conclusion

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!

Questions?

Contact Kerry Scannell, CCS, CPC, coding auditor/trainer; or Ashley Richards, RHIT, coding manager.