progress notes/discharge summary
What is the overall consensus of having an intensivist document what one is looking for in the chart through a natural progression and coding it vs. querying the attending to be able to code it. There are varied opinions on this and a lot of inconsistency.
Comments
I don't understand the question: If you are asking 'must' a condition be noted in a summary in order to be coded, I adamantly state: 'no'. If the condition is adequately documented in H&P, notes, consult, by a clinician licensed to designate the condition , it should be coded as long as there is no dissonance.
Paul Evans, RHIA, CCDS
Cut, Copy & Paste difficult in this Forum. Please see notice from RAC to Hospitals on this matter:
MLN Matter
SE1121 Revised
What you are asking is controversial, and your locate site may have particular rules regarding documentation and coding. There is nothing in Coding Clinic that states a condition 'must' be in a summary in order to be coded. If anyone makes this statement, ask them to providence evidence.
Subscriber’s Note: If you missed any of the MLN Matters® Articles notices as of June 2007, please review the archive available at: https://list.nih.gov/cgi-bin/wa.exe?A0=MLNMATTERS-L.
Are 'you' a physician asking if the attending has to confirm a diagnosis that has been already stated by a provider in the record?
There are some excellent publications by HCPRO that answer this nicely, and I'd quote, but these are copy write protected. AHIMA 2012 makes this statement:
A healthcare entity’s query policy should address the question of who to query. The query is directed to the provider who originated the progress note or other report in question. This could include the attending physician, consulting physician, or the surgeon. In most cases, a query for abnormal test results would be directed to the attending physician.
Documentation from providers involved in the care and treatment of the patient is appropriate for code assignment; however, a query may be necessary if the documentation conflicts with that of another provider. If such a conflict exists, the attending physician is queried for clarification, as that provider is ultimately responsible for the final diagnosis.
Agree with this. For example if the nephrologists documents ATN, we would code that regardless of whether or not it is confirmed by the attending. However, the caveat for me is that if the nephrologist documented a diagnosis that is way outside their specialty and the attending and other docs are not saying it, I would confirm with attending. For example, sometimes the nephrologist may document sepsis on a patient and the attending and other consultants are not saying sepsis. I would want to confirm that the attending agrees with this dx.
Katy