Inpatient queries

abby.belcher@sih.netabby.belcher@sih.net
in Clinical & Coding

Hi, quick question for those who are inpatient coders or CDI staff that do second level reviews after discharge.

My organization is having discussion surrounding the following coding guideline.

Section lll. Reporting Additional Diagnoses '/General rules for other (additional) Diagnoses

"The following guidelines are to be applied in designating "other diagnoses" when neither the Alphabetic Index nor the Tabular List in ICD-10-CM provide direction. The listing of the diagnoses in the patient record is the responsibility of the attending provider".

Does this mean that all inpatient queries after discharge must be given to the attending physician only?

Comments

  • KBecker@skagitregionalhealth.orgKBecker@skagitregionalhealth.org

    I think it depends on they query. The provider completing the discharge summary should have the final say on any medical diagnosis. If the query is about a procedure then the provider completing the procedure should answer it. Do you have examples?


    This post was from January --has there been resolution of this discussion at your organization? What was the outcome?

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