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Pathology Report as part of the Medical Record

Melissa Posted Fri 10th of January, 2020 10:30:49 AM
Hello, I have recently started coding for a hospital- owned physician clinic. I reviewed the signed dictation for a clinic visit and placed the visit in a hold status pending receipt of the pathology report from the hospital pathology dept. here is my question: the previous coder stated that the pathology report results had to be added into the clinic physician's visit dictation and that dictation amended with the pathology results. She stated the path report could not be a separate document within the record that he references. Is this correct?
SuperCoder Answered Mon 13th of January, 2020 08:01:54 AM


Thanks for your question.

The guidelines you are referring to may depend on the payer or client specific guidelines which may require you to add the pathology report results.

The results of a test can be reported as the diagnosis only if they are interpreted by a physician, according to the CMS memo. This is significant for pathology and laboratory coders because some lab procedures necessarily entail a pathologist's interpretation, while others do not.

Hope this helps.

Melissa Posted Mon 13th of January, 2020 08:47:12 AM
Thank you....I apologize,but I'm not sure I understand completely. Does that mean that there is no coding mandate that says the final path report must be added to the dictation of the physician who saw the patient in his office and that dictation re-signed? If i am understanding correctly, the two separate documents are sufficient within the record, is that accurate? Also, the second statement that you made regarding the results of a test being reported....if the pathology report is signed by the pathologist, then that diagnosis can be reported for the office that correct? Thank you very much for your time, I want to make sure I am doing things correctly
SuperCoder Answered Tue 14th of January, 2020 04:36:10 AM

Thanks for your question.

It is always best to code to the highest degree of specificity.

According to coding guidelines, in the outpatient setting you can code for signs and symptoms if there is no definitive diagnosis by the end of the visit. If it is possible, you can hold your claims until pathology results are reported and you have a definitive diagnosis.

There is no specific mandate, but it may be due to your payer policy that the claims are hold up for the definitive diagnosis.

If your physician includes a key word like mass or some other term that may describe a serious condition in the procedure notes, you should definitely hold those claims until the pathology report returns.

According to CMS transmittal states, "If the physician has confirmed a diagnosis based on the results of the diagnostic test, the physician interpreting the test should code that diagnosis. The signs and/or symptoms that prompted ordering the test may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis."

Hope this helps.


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