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Q&A: Using tumor board notes post discharge

CDI Strategies, October 13, 2011

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Q:  Some physicians are uncomfortable making addendums to the discharge summary to include the pathological findings (e.g., malignancy). Instead, they dictate a tumor board note to summarize the course of treatment and final pathological diagnosis. However, the tumor board note is usually dated a few days after the patient is discharged. When a condition meets guidelines for the inpatient admission, is it appropriate to use documentation dated outside the inpatient admission for coding purposes?

A: You may report an ICD-9-CM code for uterine cancer if the tumor board note:
  • Qualifies as a “cancer staging form” as outlined in American Hospital Association’s Coding Clinic for ICD-9-CM, Second Quarter 2010, pp. 7–8
  • Is part of the permanent medical record for that encounter
  • Is signed by the attending (not a consulting) physician for that admission
Refer to the above Coding Clinic and your facility’s medical staff bylaws or HIM or coding policies and procedures for further clarification. If the scenario meets these requirements, report ICD-9-CM code 625.8 for the uterine mass and ICD-9-CM code 179 for the additional diagnosis of uterine cancer. If the pathological report was present on the chart before final coding without a cancer staging form signed by the attending physician, and there is no documentation in the record of its findings by any treating physician, you should query the physician. Consider the following query:
 
Dear Dr. Staging;
According to Coding Clinic, Third Quarter 2008, pp. 11–12, and the ICD-9-CM Official Guidelines for Coding and Reporting, we may not report and code abnormal findings on the pathology report unless the provider indicates their clinical significance. Now that the pathology report is available, if appropriate, could you please clarify the patient’s diagnoses in your documentation based on these findings?
 
The coder or CDI specialist should include the findings or pathology report for the physician’s inspection with the query. Refer to Coding Clinic, Third Quarter 1992, p. 7 for additional guidance.
 
Editor’s Note: James S. Kennedy, MD, CCS, managing director of FTI Consulting in Atlanta, and Sandra L. Sillman, RHIT, PAHM, DRG coordinator at Henry Ford Hospital & Health Network in Detroit, answered this question in the August 14 issue of JustCoding.com.



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