Do you query surgeon directly?

jhouck@capitalhealth.orgjhouck@capitalhealth.org
in Clinical & Coding

Would you please advise of your policy regarding querying for clarification of surgical procedures and complications?  As CDI we query directly to the surgeon but if the query needs to be resubmitted retrospectively our coders feel they must query to the attending. 

Our thought is if the surgeon is responsible for the OP report they should be responsible to clarify it.

Thank you for your help~


Comments

  • jillian.bisbejillian.bisbe
    We query the surgeon. Doesn't seem like a fair question to ask the attending.
  • jhouck@capitalhealth.orgjhouck@capitalhealth.org
    jillian.bisbe said:
    We query the surgeon. Doesn't seem like a fair question to ask the attending.

    Even your coders go directly to the surgeon retrospectively?

    Thank you for your response we agree!

  • jillian.bisbejillian.bisbe
    Our coders do not send queries. We (CDI) took over that whole process about a year ago. If the coder finds an opportunity, they send it to us for a query. It has improved our queries and responses.
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    I query the surgeon directly.  The surgeon can better determine if an outcome is a complication versus ‘expected’ and integral to certain procedures.  
  • jhouck@capitalhealth.orgjhouck@capitalhealth.org

    Thank you everyone.



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