Health Information Management

Tip of the week: Check the anesthesiology note for missed CCs/additional diagnoses

HIM-HIPAA Insider, November 13, 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.

This tip was adapted from the November 1, 2007 issue of CDI Strategies. For more information, click here.

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