Attending physician and covering physician

lindenbm@bellsouth.net

We had a situation here at my hospital where the CDS queried the author of the DC summary, who was covering physician for the attending. As his answer was in conflict with the cardiologist's progress notes our coding manager said that we had to query the attending. My feeling is that with a group practice who cover for each other on a regular basis, is this necessary. In my mind they all are essentially the attending, like a hospitalists group. What are your thoughts? Do I need to write a policy?

Thank you,
Mary Lindenboom, RN, BSN, CCDS
Clinical Documentation Manager
Flagler Hospital
Saint Augustine, Florida
904-819-4254

sharon.cole

Depends...Did the attending only see the patient on admit and the covering physician assumed care and so therefore has all the information needed to make a clinical judgment? Who evaluated and made determinations based on labs, tests, etc. MOst importantly, what is clinically supported by the documentation.
Then there is also the problem of many insurance companies only wanting to see the DC summary, so that document certainly needs to be correct so that it reflects what is coded, which may require a query.
Policies are always good so that you are consistent. Anytime you have conflicting information that needs to be coded, it's best to get clarification.
Sharon Cole, RN, CCDS
Providence Health Center

lindenbm@bellsouth.net

Thank you.

With this particular group they cover interchangeably throughout the admission. One doctor could round in the hospital M, W, F and another T, Th, S and so on. I just couldn't find anything documented by AHIMA or elsewhere which clearly stated that you had to go back to the attending.

Mary

katysuegood@gmail.com

We have a similar system (intensivist/hospitalist teams) and often our attending is not our discharging MD. We tend to query the MD that is currently taking care of the Pt and if a discrepancy was identified in the D/C summery, we would likely query the discharging MD. I have never been told that the query HAS to go the attending but when I see something that I think would be especially sticky I tend to ask the coder whom they would prefer it goes to, if a coder has been assigned to it. Ultimately I want the query to be accepted by the Coder, so if they were adamant that it needed to go to the attending, I would probably go with that.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404