Query Using consultant documentation and Resp failure

clare

Hello, 

Pt seen inpatient  by PCP  who documented morbidly obese patient and having severe obstructive sleep apnea with possible obesity hypo ventilation based on severe hypoxemia. Queried hospitalist for morbid severe obesity with alveolar hypoventilation. ( included this Md assessment) MD  Response was untreated obstructive sleep apnea with severe hypoxic respiratory failure at night.

My question:1. Can I use the PCP diagnosis?  if not do I query if it is acute or chronic respiratory failure?

Thank you,

Clare

Dcarey

Hi Clare,
Are you able to verbally query the hospitalist for further clarification?  If you can speak to the hospitalist a little education sounds beneficial and offer the initial diagnoses again or ask for clarification of acuity and  clinical indicators that support severe hypoxic respiratory failure "at night"  protective against a possible clinical validation denial? Hope that helps, good luck. 
Thank you,
Dawn 

lprescott1

if the PCP documentation is part of the medical record for the encounter you certainly can assign codes from it- Of course the hospitalist (attending) supercedes if any of the documentation contradicts. also any uncertain diagnosis written by the PCP-  (possible obesity hypo ventilation syndrome) would have to be documented at the time of discharge to be considered. 

clare

Also not sure I can use the Respiratory failure as its only documented at night which is the PCP diagnosis but 

clare

Thank you for your responses. 
 I did query the Hospitalist and he did not agree, felt patient needed more of a work up in the outpatient before assigning this DX.