PDx

edie.brown1edie.brown1
in Clinical & Coding
A 2004 coding clinic states that a diagnosis from a consultant can be coded as long as the dx does not conflict with the attending. Would you ever assign a PDx based solely on a consultant's documentation (and the attending never said it)? It has always been my practice to query the attending for the PDx.  Although I can't find anything specifically addressing this, I feel it is best practice to have the attending document the PDx. 

Comments

  • kwilliams@halifaxrmc.orgkwilliams@halifaxrmc.org

    The attending has to state the principal diagnosis.

  • kelly.harneykelly.harney
    You can take the specificity (i.e. Aspiration PNA, or Acute Systolic heart failure) from the consultant.  That would not be considered a conflict.  So if the Attending is stating PNA and ID further specifies it as Aspiration PNA-treated and meeting the definition of Pdx, it would be perfectly acceptable to code that as the Pdx.
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