conflicting documentation

morrisonbalrock@aol.com

Looking for some input as to what "conflicting" documentation is, we are in agreement that when consultants and attendings(hospitalists) have different opinions its conflicting and need clarification, but we have residents who also document in the record and their terminology may differ from the attending (ie azotemia vs renal failure or acute kidney injury) Any thoughts
thanks
Pat Morrison RN,BS,CCM
Clinical Documentation Nurse

arsusott@msn.com

I always just use the below coding clinic as my guide... a prime example would be a patient that comes in with a specific pna (i.e. say aspiration) and it is mentioned a couple times as aspiration pna but then they start just documenting pna with no change in medications and then d/c. To me there is conflicting information as to whether it was asp pna or just simple pna...



AHA Coding Clinicâ for ICD-9-CM, 2Q 2000, Volume 17, Number 2, Pages 17-18



Question:

I am requesting clarification of what appears to be conflicting direction between an AHIMA Practice Brief and the Official Coding Guidelines. The AHIMA Practice Brief on Data Quality states that coding professionals may "assign and report codes, without physician consultation, to diagnoses and procedures not stated in the physician's final diagnosis only if these diagnoses and procedures are specifically documented by the physician in the body of the medical record and this documentation is clear and consistent."



The Official Coding Guidelines ODX #2 states "When the physician has documented what appears to be a current diagnosis in the body of the record, but has not included the diagnosis in the final diagnostic statement, the physician should be asked whether the diagnosis should be added."



Answer:

The two statements listed above are not inconsistent, but reinforce each other. When the documentation in the medical record is clear and consistent, coders may assign and report codes. If there is evidence of a diagnosis within the medical record, and the coder is uncertain whether it is a valid diagnosis because the documentation is incomplete, vague, or contradictory, it is the coder's responsibility to query the attending physician to determine if this diagnosis should be included in the final diagnostic statement. All diagnoses should be supported by physician documentation. Documentation is not limited to the face sheet, discharge summary, progress notes, history and physical, or other report designed to capture diagnostic information. This advice refers only to inpatient coding.