Health Information Management

Q&A: ACDIS Board weighs in on queries to the attending physician

CDI Strategies, April 16, 2009

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Q:My facility’s policy requires us to address all queries to the attending physician, regardless of which physician wrote the progress note that requires clarification. However, I thought that we could pose queries to any physician that provides documentation in the record. Can you explain?

A:This answer is situational. If your query is to clarify the primary diagnosis, then you should query the attending physician. Anytime the primary diagnosis is in question, ICD-9-CM coding guidelines state that you must query the attending physician. This is not to say that you should always query the attending physician when he or she has not documented the diagnosis.

For example, if the attending states, “chest pain, rule out MI,” then orders a cardiac consult, and the cardiologist confirms the MI, the coder can code from this without the attending having documented the MI—as long as the attending physician’s documentation does not conflict with the consult.
 
If the attending documentation conflicts with the consult, however, you must query the attending for the clarification. Also, if there is conflicting documentation among the attending and other physicians regarding secondary diagnoses, you should clarify with the attending.  
 
Per the October 2008 AHIMA Practice Brief, “Managing an Effective Query Process”:
A healthcare entity’s query policy should address the question of who to query. The query is directed to the provider who originated the progress note or other report in question. This could include the attending physician, consulting physician, or the surgeon. In most cases, a query for abnormal test results would be directed to the attending. Documentation from the provider involved in the care and treatment of the patient is appropriate for code assignment; however, a query may be necessary if the documentation conflicts with that of another provider. If such a conflict exists, the attending physician is queried for clarification, as that provider is ultimately responsible for the final diagnosis.
(Editor’s note: Robin R Holmes, RN, MSN, manager of clinical documentation improvement for DCH Health System in Tuscaloosa, AL, provided this answer.)
 
A:Queries can be addressed to any physician, but ultimately the information is equated to the attending physician in external data. This is a facility-level decision. We often see facilities query consultants regarding their consultative documentation, or query the surgeon if the question is related to the procedure, but neither may be the attending physician. If we don't get a response, we go to the attending physician (as he requested the consults), since the external data will be equated to the attending physician.
 
(Editor’s note: Garri L. Garrison, RN, CPC, CMC, CPUR, director of acute care services for 3M Health Information Systems Consulting Services, provided this answer.)



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