Pathology/Lab Coding Alert

Know when to ask for clarification.

Sometimes you face a pathology report that seems to contain conflicting statements, or that has missing information that is critical to selecting an appropriate code, or simply a paper report that has illegible handwriting.

These are all cases that might warrant a "query" to the pathologist so that you can update the medical record to accurately reflect the situation. Read on for some tips to improve your query process.

What it is: "A query is a routine communication and education tool used to advocate complete and compliant documentation," according to the American Health Information Management Association (AHIMA). "The desired outcome is an update of the health record to better reflect the provider's intent and clinical thought process," AHIMA adds.

Make a Query Form

Written queries are best, but they can be verbal if you document the exchange. You can use email for a query if your system is secure and HIPAA-compliant, according to Leonta Williams, RHIT, CPCO, CPC, CEMC, CHONC, CCS, CCDS, director of medical coding at Georgia Cancer Specialists in a presentation at American Academy of Professional Coders Regional Conference in Salt Lake City.

Ideally, you will have a query form that you fill out to ensure consistent procedures for gathering and documenting information. The following guidelines will help you make good use of this tool:

• Your query forms should:

            o List the patient's name, date of service, medical record number, provider's name, name and contact of the individual sending the query, date of query
            o Present the facts of the scenario
            o Using a question, identify where clarification is needed.

• Query forms should not:

            o Be designed so that the only thing needed is a physician's signature
            o Indicate any financial impact.

Hone Your Question Skills

The clarification question that you write is the key to a query, and there's an art to writing a good one. For instance, you should steer clear of "leading" questions that box the pathologist into one response. You should also avoid statements that imply error and could spark a defensive response.

For instance: Don't say, "You stated in the pathology report that you did a bone biopsy exam but you did not note that you did a decalcification. Please add that documentation to the report."

Better: "The pathology report documents a bone biopsy exam. Were there any other common ancillary procedures performed, such as a decalcification or special stains, that need to be documented?"