Tissue findings interpreted by a pathologist are not equivalent to the attending physician’s medical diagnosis based on the patient’s clinical condition. If the attending physician has not indicated the significance of an abnormal finding within a pathology report, the coder must query to determine if the finding may be reported.
Coding guideline III.B. states:
Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added. Please note: This differs from the coding practices in the outpatient setting for coding encounters for diagnostic tests that have been interpreted by a provider.
One pathological finding that may have implications on DRG assignment is metastasis. The attending physician may document a diagnosis of primary malignancy within the record, but fails to indicate the presence of any metastatic sites. If a pathological finding of metastasis was found in the sample, a query should be generated to confirm the clinical significance of this finding. A sample query is found below.
*Right colon and ileum with findings of adenocarcinoma extending through the muscularis propria into the surrounding pericolic soft tissue – Thirteen of thirty-three lymph nodes positive (Pathology Report)
*No documentation elsewhere in record regarding metastatic sites
Can you confirm any metastatic sites based on the pathology results?
In this example, there is no evidence in the pathology report of more than one possible metastatic site. If the coder listed options for response (i.e. – abdominal lymph nodes, other site, unable to determine), the query would be considered leading. Options should only be listed if more than one specific site can be supported by the pathology report documentation.
The information contained in this query advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
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