Ask ACDIS: Non-treating physician responses to queries

Association of Clinical Documentation Improvement Specialists, September 1, 2015

Q: May a physician/provider, who does not attend the patient during an episode of care but does act in an advisory capacity for the CDI and/or coding departments, answer a formal query? Could that documented response be used as a basis for compliant code assignment?

A: No. Official Guidelines for Coding and Reporting clearly indicate that provider documentation should come from a provider who is legally accountable for establishing the patient’s diagnosis. Therefore, documentation from a physician/provider who did not attend to the patient during the episode of care is not appropriate for code assignment.

According to the Guidelines, the term provider is defined as a “physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis.” On p. 97, the Guidelines add that “medical record documentation from any provider involved in the care and treatment of the patient may be used to support the determination of whether a condition was present on admission or not” (emphasis ours). Additionally, p. 97 of the Guidelines adds that “issues related to inconsistent, missing, conflicting or unclear documentation must still be resolved by the provider.”

Furthermore, according to the CMS State Operations Manual Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, §482.24(c)(1):

All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures (again, emphasis ours).

Coding Clinic provides a couple of additional references pertinent to this question. Coding Clinic, First Quarter 2014, pp. 11–13, includes similar references as above and is worth researching. In addition, Coding Clinic, First Quarter 2004, pp. 18–19, adds the following advice regarding appropriateness of code assignments based on the documentation in the medical record by a physician other than the attending physician:

Code assignment may be based on other physician (i.e., consultants, residents, anesthesiologist, etc.) documentation as long as there is no conflicting information from the attending physician. Medical record documentation from any physician involved in the care and treatment of the patient, including documentation by consulting physicians, is appropriate for the basis of code assignment. A physician query is not necessary if a physician involved in the care and treatment of the patient, including consulting physicians, has documented a diagnosis and there is no conflicting documentation from another physician. If documentation from different physicians conflicts, seek clarification from the attending physician, as he or she is ultimately responsible for the final diagnosis.

In summary, ACDIS does not condone the practice of a provider, be that person a nurse, physician assistant, physician, or other—including a physician advisor to CDI—answering a query when serving in a nonclinical capacity without direct responsibilities for the patient in question. Queries must be directed to physicians directly involved in the care or treatment of the patient. In the rare instance of a physician who unexpectedly leaves a facility and has unanswered outstanding queries that must be addressed, hospital-specific HIM rules and regulations pertaining to chart completion/close-out would apply.

Editor’s note: This question was posed to the ACDIS Advisory Board, which reviewed and researched the question and drafted the response. It should not be construed as legal advice, just the advisory board’s consensus opinion on this issue.