Health Information Management

Q&A: Coding from documentation other than that of the attending physician

CDI Strategies, December 4, 2008

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Q:When a clinical condition suggests a more specific diagnosis, and a physician from a different specialty than the attending physician documents it, can a coder report the more specific diagnosis (if the facility includes this provision in its bylaws)?

A: If two or more physicians provide a diagnosis and there is no conflict, then a coder may report all the diagnoses. The following excerpt from Coding Clinic, First Quarter, 2004, pp.18-19, provides clarity:

"Question: Please provide clarification regarding the appropriateness of code assignments based on the documentation in the medical record by a physician other than the attending physician. Previously published Coding Clinic advice has allowed using documentation from the anesthesia report. . .

Answer: Code assignment may be based on other physician (i.e., consultants, residents, anesthesiologist, etc.) documentation as long as there is no conflicting information from the attending physician. Medical record documentation from any physician involved in the care and treatment of the patient, including documentation by consulting physicians, is appropriate for the basis of code assignment.

A physician query is not necessary if a physician involved in the care and treatment of the patient, including consulting physicians, has documented a diagnosis and there is no conflicting documentation from another physician. If documentation from different physicians conflicts, seek clarification from the attending physician, as he or she is ultimately responsible for the final diagnosis. This information is consistent with the American Health Information Management Association's (AHIMA) documentation guidelines."

Regarding the use of a more specific diagnosis by a physician other than the attending, this can get dicey. My gut is that it is OK given some references provided in Coding Clinic. These include the following Coding Clinic, Fourth Quarter 2004, pp. 77-78, excerpt:

"Effective October 1, 2004, a change has been made in the classification of unspecified cerebrovascular accident (CVA) or stroke. Prior to this change, these conditions were indexed to code 436, Acute, but ill-defined, cerebrovascular disease … Please note that if additional information is available describing the stroke or CVA as embolic (434.11), hemorrhagic (430, 431, 432.0-432.9) or thrombotic (434.01), the more specific code should be assigned instead of 434.91."

Note that if more specific information is available from a physician other than the attending, Coding Clinic requires hospitals to report the more specific code. Unfortunately, Coding Clinic has not defined what is conflicting and what is not conflicting between qualified providers. The only example that I can find is in Coding Clinic, First Quarter, 2004, which states the following:

"If the attending physician documented "breast mass" and the pathologist documented "carcinoma of the breast," this would be conflicting information requiring clarification from the attending physician."

This seems to suggest that if an attending physician documents "breast mass" and a consulting physician documents "carcinoma of the breast," this is considered conflicting. Given these two conflicting types of opinions, the only solid answer is the one provided in Coding Clinic.

Editor's Note:James S. Kennedy, MD, CCS, director for FTI Healthcare in Atlanta, GA answered this question.



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Comments

1 comments on “Q&A: Coding from documentation other than that of the attending physician

Marian (3/14/2012 at 5:19 AM)
Great insights (as awylas) into our sometimes-nutty healthcare system, Lisa! I'm interested in knowing that since the UK adopted it in 1995 and France in 1997 , what the workflow impacts and cost burdens have been in those countries, if known, and what corresponding solutions, if any, have been implemented there by physicians and/or healthcare systems?Best,Paul

 

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