query impact

Here's a scenario that I would like to present. Our institution wants the attending provider to state the primary diagnosis in the discharge summary and in their progress notes. A consultant in the case says sepsis and it is well supported and treated and the attending is only saying pneumonia but not mentioning sepsis. CDI queries the attending if he agrees with the consultant and he does and includes sepsis in his progress notes. sepsis is coded as the primary diagnosis. Granted that sepsis was already documented in the chart by another provider, should the CDI take financial impact for the primary diagnosis?

Comments

  • I would say yes, your query clarified what the consulting MD stated and helped support the higher level of acuity

  • Yes, there was conflicting documentation between the attending and a consultant. This requires a query to clarify, therefore CDI should take credit.

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