Q&A: Querying pathology results

Q: If the radiology or pathology report stated ovarian cancer but the physician never documented an ovarian mass, is it true you can’t use a present on admission (POA) query to capture the ovarian cancer because the physician made no reference to it? Would you need to use either an open-ended or multiple-choice query to capture the diagnosis using appropriate clinical indicators?

A: In this scenario, you would need to query the provider to capture the pathology results so you could further specify the ovarian mass that was POA as ovarian cancer.

If the documentation of ovarian cancer meets the definition of a principal diagnosis, the specificity will change the DRG. You are correct that you would need to query in a format that is appropriate to the question. However, because this query is to further specify an existing diagnosis, you could use a yes/no format. Yes/no queries can be used when substantiating or further specifying a diagnosis that is already present in the health record (e.g., findings in pathology, radiology, and other diagnostic reports) with interpretation by a physician.

Querying for pathology results after discharge can be challenging. From a clinical standpoint, I do understand the hesitancy and I have heard physicians come out and say, “I didn’t treat it.” But if a biopsy is performed, the provider saw something abnormal and worked it up, even if the result came back after the patient was discharged.

I also understand from a clinical perspective, we want to make sure the patient has a follow-up with an oncologist, surgeon, and/or a primary care physician to discuss the results and treatment options. Not documenting anything can put the patient at risk as well as the provider. A test was performed and there is no documentation in the medical record on the results or whether the patient was informed. I have worked with many organizations and providers to create language that is comfortable for the provider in these situations. I would suggest creating a standardized statement that includes the pathology result, the patient being notified, and any scheduled follow-up. For example:

After the patient was discharged, the pathology was resulted. The pathology confirms neoplastic disease (be specific). The patient has been notified of the results and has a scheduled follow-up on XX Date with Dr. _____ (oncology/surgery) to discuss treatment options.

This statement allows for the appropriate capture of the diagnosis, demonstrates follow-up with the patient, and shows that a “hand off” plan is in place.

The same could be said in the reverse situation. The patient has suspected neoplastic disease, and after a biopsy or surgical intervention, the patient’s pathology is negative for neoplastic disease. We would want to ensure the proper documentation tells the patient’s story accurately. A query would be needed in this case as well to confirm or refute the pathology results.

Editor’s note: Kim Conner, BSN, CCDS, CCDS-O, CDI education specialist for ACDIS/HCPro based in Middleton, Massachusetts, answered this question. Contact her at kconner@hcpro.com.