To validate or not to validate?

If a consulting physician is documenting a diagnosis and it is NOT clinically supported. The attending is not documenting the diagnosis.  i.e. nephrology diagnosis sepsis.  Do you still query for validation? If so, to the consulting physician who documented the questionable diagnosis or the attending "Captain of the Ship"?

Comments

  • edited March 13
    You have to ask yourself - If you sent to the Counsultant, and that person responds and confirms  - are you going to code the condition?  

    Personally, I would not code something such as SEPSIS if a consultant charted it, but the Attending never mentions the sepsis.   I’d fashion a query to the Attending and ask the Attending if he/she agrees with the Consultant.  

    See AHIMA 2019 Guidelines for Achieving a Compliant Query Practice 2019 (yes/no)

    In your case, with the expection the Attending would say there is no sepsis.   Attendings tend no to like this flow, but as the Attending, the duty to address dissonance lies with the Attending.

    on pad, excuse typos 

    Paul Evans, RHIA, CCDS
  • Good point!  Yes, expectation is the Attending would say there is no sepsis but, unfortunately, in my experience it puts it at risk for Attending agreeing to a diagnosis not validated. 
  • Perhaps, but in the scenario listed, it is incumbent upon the Attending to provide input as the Captain of the Ship.   We should be able to expect a clinically accurate response from the Attending.  
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