Corporate Compliance

Tip: Clarify conflicting documentation

Compliance Monitor, December 14, 2011

MLN Matters article SE1121 emphasizes that coders must consider all documentation from licensed treating physicians and attending physicians when assigning a principal diagnosis. When attending and secondary physicians' documentation conflicts (e.g., sprained ankle and fracture), query the attending physician for clarification.

Coding Clinic, First Quarter 2004, pp. 18-19, encourages coders to assign codes based on attending physicians' documentation when a conflict exists and the coder does not query the attending physician to resolve it.

However, MLN Matters article SE1121 says that an attending physician's failure to mention a consultant's diagnosis does not create a conflict. "There are a number of reviewers that are taking the position that final diagnoses cannot be coded unless they're in the discharge summary," says James S. Kennedy, MD, CCS, managing director at FTI Consulting in Atlanta. "They're taking positions that unless the attending physician cites the consulting physician's diagnosis, the diagnosis cannot be coded. That is so contrary to this advice."

Editor’s Note: The following tip is adapted from an article in the December 2011 Strategies for Health Care Compliance.

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