Two attendings--two diagnoses

dog

A patient is admitted with a diagnosis of fluid overload d/t noncompliance with hemodialysis. The next day is the attending's day off and the pt is covered by his associate. She diagnoses acute on chronic systolic heart failure and sends him home that day.

So here are two physicians who are both the attending who are taking the same set of data and interpreting them differently. I always have trouble with these. Is it the last voice that counts?

Thx,

Renee

Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital

stacy.vaughn

1Q 2004 coding clinic:

Question:

Please provide clarification regarding the appropriateness of code
assignments based on the documentation in the medical record by a
physician other than the attending physician. Previously published Coding
Clinic advice has allowed using documentation from the anesthesia report.
Our coders have interpreted that the lack of contrary documentation from
the attending can be perceived as concurrence with the anesthesiologist.
We have recently been advised that we cannot use a consultant's note
without "confirmation" from the attending physician. Our coders tell us
that it is operationally impossible to confirm every single diagnosis or
condition that the consultant writes. Of course, if there is conflicting
information, we will query the attending physician for clarification. Can
you comment on whether our interpretation of coding instructions is
correct?

Answer:

Code assignment may be based on other physician (i.e., consultants,
residents, anesthesiologist, etc.) documentation as long as there is no
conflicting information from the attending physician. Medical record
documentation from any physician involved in the care and treatment of the
patient, including documentation by consulting physicians, is appropriate
for the basis of code assignment. A physician query is not necessary if a
physician involved in the care and treatment of the patient, including
consulting physicians, has documented a diagnosis and there is no
conflicting documentation from another physician. If documentation from
different physicians conflicts, seek clarification from the attending
physician, as he or she is ultimately responsible for the final diagnosis.
This information is consistent with the American Health Information
Management Association's (AHIMA) documentation guidelines.



Stacy Vaughn, RHIT, CCS