Physician Concurrence

cturveycturvey
edited May 2016 in CDI Talk Archive
Recently I was challenged by a coder that stated "just because a physician douments the diagnostic findings (of a test, xray, CT etc) it does not necessarily mean he concurs." I was asked to find some "official" ruling on this matter. Anyone know of such? I have had attendings disagree with a consultant's findings but never with test results. If it is noted in the PN it is an indication of concurrence correct? Thanks

Comments

  • tiffany_susantiffany_susan
    edited May 2016

    But it does mean he agrees!!

    Abnormal findings:
    Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic
    results) are not coded and reported unless the provider indicates their
    clinical significance. If the findings are outside the normal range and
    the attending provider has ordered other tests to evaluate the condition
    or prescribed treatment, it is appropriate to ask the provider whether the
    abnormal finding should be added.
    ICD-9-CM Official Guidelines for Coding and Reporting
    Effective October 1, 2009
    Page 94 of 112


    Thank You,
    Susan Tiffany RN, CCDS
    Supervisor Clinical Documentation Program
    Guthrie Healthcare System
    phone: 570-882-6094, pager #465
    fax: 570-882-6768
    email: tiffany_susan@guthrie.org
    "Twenty years from now you will be more disappointed by the things you
    didn't do than by the ones you did do. So throw off the bowlines. Sail
    away from safe harbor.Catch the trade winds in your sails. Explore. Dream.
    Discover." Mark Twain
  • cturveycturvey
    edited May 2016
    I agree but the literal translation of the coding guidelines sounds like the MD should be queried as to the abnormal findings significance. The case revolves around a patient who underwent thoracotomy. Pneumothorax was suspected on the opposite side. CT was ordered to confirm it and treatment was rendered and monitored. We want to pick it up as an MCC. Coding believes it is inherent in the procedure so therefore can not be captured. The MD noted the findings of the CT in his PN and ordered treatment. I do not feel it is necessary to query him as to its' significance. Coding won't code it unless we do.
    Any other thoughts?

    Carol A. Turvey RN, BSN, CPHQ
    Accretive Health
    IBP Clinical Documentation Program
    Director
    484-892-9086 (cell)
    cturvey@accretivehealth.com
  • janrumdavisjanrumdavis
    According to the coding auditors that come to our facility cannot code the diagnosis if MD is just stating in progress note the results of test. For example, if MD states CXR shows pneumothorax cannot code as MD is just stating what the cxr shows not that he/she is in agreement. He/she must also document pneumothorax with their "impression" or list of problems/diagnoses.
  • NormaBNormaB
    edited May 2016
    We would code it if he wrote it in the Progress Note. That's his reason for doing the CT. In a peerfect world

  • cturveycturvey
    edited May 2016
    Would that stand true if treatment was ordered and rendered?

  • catladyrncatladyrn
    I don't think a contralateral pneumothorax (and it's a cc, not an mcc, I believe) is inherent to a thoracotomy. Ipsilateral, yes.

    I asked in here a few weeks ago if radiology results that were copied and pasted into an progress note in an EMR could be used, and the group consensus was that they could be.

    I don't agree that a physician has to state a diagnosis under "impressions" or similar heading, if they've described their diagnosis elsewhere in their note. Normally, even in written records, if a physician cites radiology or lab results and doesn't contradict them, I've always felt they became part of the note. However, in the case cited here, a query couldn't hurt.

    Renee

    Linda Renee Brown, RN, CCRN, CCDS
    Certified Clinical Documentation Specialist
    Banner Good Samaritan Medical Center
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