Queries
Our CDI Program is going into it's 3rd month and we had a situation come up 2 times already. Example #1: Pt admitted with UTI which is clearly docmunent in the chart (PDx). ID is consulted and in her consult (along with mutilbacterial UTI) poss asp pneumonia is documented and throughout progress notes ID writes ?asp pneumonia. Pt is discharged home. Discharge summary is dictated quickly. Primary MD does not list asp pneumonia in diagnosis but does mention "aspiration pneumonia was treated by MD with IV zosyn" in body of summary. The coder queried the primary MD if pt had asp pneumonia. The MD response was "NO". What now? Since it is dictated in d/c summary can we code the asp pneumonia? (I know it is wrong) but it was mentioned to disgard the query because the coder should have nevere quieried. I am so confused. We have also had another incident similar to this but with a different coder. Please advise. Thanks!
Dawn Vitalone,RN, CDI Specialist
COmmunity Hospital
Dawn Vitalone,RN, CDI Specialist
COmmunity Hospital