Pinson&Tang Resources

Coding Possible Malignancy Diagnoses When Pathology Report is Pending

July 7, 2023

We are concerned about the consequences of Coding Clinic® Second Quarter 2023 advice to code a possible malignancy diagnosis when the pathology report is pending.  We believe this advice is both inconsistent with standard HIM coding practices and creates a potential harm for a patient when incorrect codes are attached to the patient’s history.

A question was asked how to code a provider’s final diagnosis statement on an inpatient: "Liver mass possibly hepatic cholangiocarcinoma, pending pathology” and whether the uncertain diagnosis guideline can be applied.

Coding Clinic® responded to assign the malignancy code because the uncertain diagnosis guideline does not make a distinction based on the type of disease (i.e., malignancy or other condition).

It has always been an HIM and coding practice standard that coding is not completed or final billed until the pathology report is available for inpatients, particularly to confirm a malignancy diagnosis. Just as you don’t code unconfirmed cases of HIV infection, we think the same can be said for malignancies, even if the uncertain diagnosis coding guideline does not prohibit it.

There can be serious consequences for patients who are assigned a malignancy diagnosis that does not have one, such as denial of medical or life insurance. Once the diagnosis code has been submitted on the billing claim, it would be extremely difficult to remove it.

Should the patient expire, or hospice care ordered, an unconfirmed malignancy may be appropriate since there is no opportunity for further workup to confirm the malignancy.  But when there is an opportunity to confirm a malignancy diagnosis, especially when a pathology report is pending, it does not make sense to do otherwise.

We recommend reviewing your organization’s policy regarding what circumstances coding may be finalized while pathology reports remain pending. In outpatient coding, coders are allowed to code from the pathology report without the provider confirming the diagnosis, while for inpatient coding, you cannot. You might also consider registering your concerns with Coding Clinic®.

As coding and CDI specialists, it is our professional obligation to ensure that coded data is as accurate as possible. Coding Clinic® is published by an important and authoritative source, but it is still only advice. It is not a law, a rule, or a regulation. In this situation where adhering to Coding Clinic® advice could lead to a significant misrepresentation of the patient’s condition, it would be wise to wait for confirmation of the diagnosis.

See our original CDI Pocket Guide for more information on this topic.

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