Health Information Management

Q&A: Ancillary providers response to queries post-discharge

CDI Strategies, November 25, 2015

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Q: We recently had attending physicians send back queries with responses by the physician assistant (PA) or nurse practitioner (NP) who documented for them. Is it acceptable for a PA or NP to answer queries after the patient is discharged?

A: This is a difficult question to answer without knowing the policies within your organization related to discharge summaries, amending summaries, and the retention of queries.

We certainly can apply code assignments from any provider (physician, NP, or PA) that has been involved in the care of the patient. So, in general, the PA or NP answering these queries is acceptable, if, of course, they provided care to the patient during the encounter.

If you ask them to amend the discharge summary, examine your organization’s policies related to who is allowed to amend discharge summaries. For example, if the PA is not the one who wrote the discharge summary, should they be the one to add a change? I would suggest you speak to your HIM director if this is an issue.

Lastly, if you ask a query due to conflict between providers (for example, the PA states one diagnosis and the attending is stating a completely different diagnosis) the clarification must come from the attending physician.

As is almost always the case in the world of CDI, coding, and medicine, it is a bit complicated!

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA approved ICD-10-CM/PCS trainer, and CDI Education Director at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.

 



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