Health Information Management

Q&A: Coding from pathology/radiology reports

CDI Strategies, September 26, 2013

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Q: If a pathologist serves as a “consulting physician,” why isn’t the coder allowed to code from his/her documentation?

A: Inpatient codes can only be assigned based on the documentation of an independent, licensed practitioner who provides direct patient care. Although a pathologist can be viewed as a “consultant,” they are not providing direct patient care. The attending physician must review, validate, and interpret the pathologist’s findings in relation to the specific patient being treated. The same is true for a radiologist, who only interprets a diagnostic study.

However, the pathology and radiology findings can be used as clinical indicators to support a query. Several editions of AHA Coding Clinic for ICD-9-CM® address the limitation of the documentation by a pathologist. Also, if a interventional radiologist provides direct patient care, their documentation could be used to assign inpatient codes.

Coding Clinic for ICD-9-CM, 3rd Quarter 2008, p. 11, states:

“…This ensures that the documentation and the codes reported are consistent with the attending physician’s interpretation since he/she is responsible for the clinical management of the case. It is the responsibility of the attending physician to gather and collate all of the findings from the consultants and other providers involved in the care of the patient… Although the pathologist provides a written interpretation of a tissue biopsy, this is not equivalent to the attending physician’s medical diagnosis based on the patient’s complete clinical picture.”

Integrating the pathologist’s findings in the health record can prove difficult at times. Often the results are not ready until after discharge. In that case, the primary provider needs to add an addendum to the health record to incorporate these findings.

Although some oncologists can tell from the tissue if it is likely malignant or not, it’s risky for the provider to document “probable” malignancy at the time of discharge if the pathology report isn’t ready. Inpatient coding guidelines allow the malignancy to be coded if it was uncertain at the time of discharge, but if pathology doesn’t support this finding, now the patient has a serious diagnosis that may be difficult to remove from their record. Discuss the limitation of inpatient coding guidelines in regards to pathology findings with your physicians and work with them to develop a cohesive solution everyone can support.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., answered this question. Contact her at For information regarding CDI Boot Camps offered by HCPro visit This article originally published on the ACDIS Blog

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