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Strategy: Check the anesthesiology note for missed CCs/additional diagnoses

CDI Strategies, November 1, 2007

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Don't overlook the anesthesiology note when reviewing a medical record. A physician in the anesthesiology department is more likely than a subspecialist to document that a patient has chronic obstructive pulmonary disorder, for example. "They (anesthesiolgists) have to give a complete body assessment in order to appropriately give anesthesia," says DeAnne Bloomquist, RHIT, CCS, chief consultant of Mid-Continent Coding, Inc., in Overland Park, KS.

A coder may code from another physician's documentation as long as the attending physician does not disagree with it, Bloomquist says. "If there's something ambiguous, the attending always has the final word," she says. Coding Clinic, 1st quarter 2004, pp. 18-19, confirms this guideline.

Just don't go overboard when interpreting this guideline, Bloomquist warns. If the only documentation for a CC is a radiology report, with no treatment of the condition, you cannot code it.

"You must get a physician to document it, otherwise it falls into the category of 'incidental finding,' which should not be coded," Bloomquist says. "I don't think you can call someone who stamps his or her signature on an EKG report as being involved in the patient's treatment."

Bloomquist also recommends that you should get the physician to document this diagnosis in the discharge summary, as it's critical to ensuring proper Medicare Severity DRG payment.

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