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Question: Positive over negative findings

When abstracting for LVO and there is conflicting documentation in the acceptable sources, for example, the radiology report states positive for LVO but the neurology report states negative for LVO, do we accept the positive finding over the negative finding? Same question for MER. If there is conflicting documentation in the acceptable sources, do we accept the positive finding over the negative finding?

Thank you.

Answer:

Cindy, Good question. Notes for abstraction do not address contradictory documentation and may need to be updated with future versions since these are new data elements.

If documentation is contradictory/conflicting, the case should be deemed "unable to determine” (select "No”.

Thank you for your inquiry.)

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: STK-OP, Data Source
Manual: Current Manual (current data collection period; prior to data transmission)
File:

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