RE: [MARKETING] [EXTERNAL] Querying more than one physician
If you query and you get an answer, even if you don't like it and clinical indicators state that there is likely a more precise diagnosis don't query again or query someone else to get the answer you want. Coders tell me the same thing on this issue.
The attending provider is responsible for the content of the record and if they are not comfortable providing a particular diagnosis then it's very disrespectful to go around them. Not to mention if your queries are part of the record an auditor will see that you queried multiple providers on the same issue. It will look like you’re fishing for a particular diagnosis (leading queries?). Not to mention if I was the physician I would be very upset that you didn’t accept my judgment and were going around me. Not a way to make friends or influence people.
Your physician advisor has talked to them, he’s not deferring to the consultants so I would drop it. You have done your due diligence in querying and taking it to the physician advisor. The attending will have to address any issues if a quality review is done, not you.
I wouldn’t call it definitive guidance, but it is ethical practice in my opinion.
Robert
Robert S. Hodges MSN, BSN, RN, CCDS
Clinical Documentation Improvement Specialist
Secretary, Nursing Professional Standards Board
Aleda E. Lutz VA Medical Center
1500 Weiss Street, ATTN PAS-136
Saginaw MI 48602
989-497-2500 x13101
Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
The attending provider is responsible for the content of the record and if they are not comfortable providing a particular diagnosis then it's very disrespectful to go around them. Not to mention if your queries are part of the record an auditor will see that you queried multiple providers on the same issue. It will look like you’re fishing for a particular diagnosis (leading queries?). Not to mention if I was the physician I would be very upset that you didn’t accept my judgment and were going around me. Not a way to make friends or influence people.
Your physician advisor has talked to them, he’s not deferring to the consultants so I would drop it. You have done your due diligence in querying and taking it to the physician advisor. The attending will have to address any issues if a quality review is done, not you.
I wouldn’t call it definitive guidance, but it is ethical practice in my opinion.
Robert
Robert S. Hodges MSN, BSN, RN, CCDS
Clinical Documentation Improvement Specialist
Secretary, Nursing Professional Standards Board
Aleda E. Lutz VA Medical Center
1500 Weiss Street, ATTN PAS-136
Saginaw MI 48602
989-497-2500 x13101
Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens