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.
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.
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