Using a PDX not stated by Attending

tvrntvrn
in CDI Talk Archive
Can I get some feedback on the idea that a PDX can be used if the attending DOES NOT state it as long as he doesnt conflict it?
I have always been of the belief that the Attending must be onboard for the PDX to be valid.
Thanks
Toni

Comments

  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited May 2016
    Standard caveat -- I am not a coder ...

    If the diagnosis was the cause for the admission ... why would the attending NOT have documented the diagnosis?
    I have trouble imagining where an attending would not have documented at least the fundamental diagnosis.
    About the only clear cut picture I can imagine is a situation where the attending essentially has documented nothing ... and then of course there would be other more pressing issues than selection of a PDX.

    If there is more specific information from a consultant, etc. and there is NO conflict ... maybe.

    As a troubling example -- if the attending persists in documenting chest pain/ACS/etc., cards consult calls it an NSTEMI, then there is clear conflict and a query is required.
    If the attending documents pneumonia, and the pulmonologist clearly tags a causative organism, then I would think the more specific type of pneumonia could be coded.

    Could you provide one or more examples?

    Don

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    Some Docs do not know the definition of the PDX. It is always easier to use the 1st listed as designated by the MD.

    But, often, a review of the record indicates the MD may list diagnoses in no particular order. In this case, the coder must always review the entire medical record to determine the condition that should be designated as the principal diagnosis. If not clear, query indicated.


    Paul Evans, RHIA, CCS, CCS-P, CCDS
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