Query second time, same visit
Is it allowable to query the new attending for the same diagnosis that a previous attending agreed with, but did not add to progress notes?
Our policy does not allow for capture by coding based on answer to a concurrent query. Documentation must be added to and PN and/or D/C summary.
Thank you,
Amy Deer
Comments
Hi,
IMO there is a literalness on this topic that is not practical. I think "not being able to query a new physician" was meant to say "you can't keep querying to get the answer you want".
i have staff that feel stressed on this topic as well. I look at it as each day's new documentation can change how the record is codded. Even if your provider said NO CHF but there was subsequent documentation saying acute, or treatment with additional Lasix, I think it's fair to ask the question.
In your case, if it has fallen off the record, and the query response is the only place you have it, it's still not in the record. I'd Query including the query response you received and any subsequent documentation.