Physician Advisor’s Corner: Coding Pathology Reports After Hospital Discharge

By Andrew Maigur, MD, system director, Physician Advisor Program

Having worked clinically as a hospitalist, I am more than familiar with the scenario of a patient being diagnosed with a mass on imaging and undergoing a biopsy; however, the final pathology reports are pending, and the patient is medically ready for discharge. A week later, the pathology report may confirm or reveal a specific diagnosis (malignant or benign), which leads to a coding query, requesting an amendment to the discharge summary with the more accurate and precise diagnosis. Begrudgingly, I would capture the diagnosis in my documentation and wonder why the coder cannot just code the diagnosis from the pathology report, as well as what the compliance or malpractice implications are for addending the medical record of a patient who has already been discharged from the hospital.

My role as a physician advisor opened my eyes to the many implications of the above-mentioned scenario, which include the following:

• We owe our patients an accurate medical record.
• An accurate medical record serves as an effective provider communication tool, especially for primary care providers, and assists with safer transitions of care.
• It also allows the coder to use a more specific code, e.g., lung mass versus adenocarcinoma of the lung.
• This, in turn, can affect your DRG (diagnosis related group), which:
  • impacts your expected LOS (length of stay);
  • changes your principal or secondary diagnosis;
  • serves as CCs (complicating conditions) or MCCs (major complicating conditions);
  • or impacts the SOI (severity of illness) and ROM (risk of mortality) scores – all of which can impact hospital and physician quality metrics and reimbursement.

The Centers for Medicare and Medicaid Services (CMS) addressed my compliance and risk concerns in the 2008 IPPS (Inpatient Prospective Payment Schedule) Rule:

“We do not believe there is anything inappropriate, unethical, or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record. We encourage hospitals to engage in complete and accurate coding.”

Also, per CMS rules, the inpatient coder cannot code a diagnosis from a pathology, or any test result for that matter, unless a clinician providing direct patient care confirms the clinical relevance of the pathology report in their medical documentation. If the provider documents a possible, probable, or suspected diagnosis that is later confirmed by pathology, then the coder is allowed to accurately code the diagnosis without any additional coding queries.

As a physician or APP (advanced practice provider), what you document in the medical record holds tremendous weight. So “THINK IN INK” and Happy Documentation. Please feel free to reach out to me or my team with any questions or concerns!

Back to the March 2022 issue of Premier Pulse

Reference: American College of Physician Advisor’s CDI Tip Sheet