Q&A: When can a consulting provider’s documentation be used for coding?

Q: If a consulting physician documents a diagnosis related to his or her specialty but the attending does not (instead simply documenting, “thank you for your assistance”) can the consulting physician’s documentation be used for coding purposes? My most experienced associate says we can but another says we have to query to determine if the attending physician agrees with the specialist.

A: If there is no conflicting information documented in the medical record between the attending physician and a consulting provider, use the documentation of the consulting physician, as explained in the AHA’s Coding Clinic, First Quarter 2004, pp. 18-19.

Let me give you an example.

An attending provider documents that a patient has “renal insufficiency,” and orders a consult. The consulting nephrologist documents “acute renal failure.” In this case, if attending physician provides no mention of the acute renal failure, the coder would either assign a code for the insufficiency or need to query the attending due to the conflicting diagnoses. Renal insufficiency is different than an acute renal failure.

But, if the attending provider documents agreement with the nephrologist, coders can apply the code for the acute renal failure. Per your question, the attending writing a statement “thank you for your assistance” does not indicate agreement with the diagnoses.

Let’s look at another example.

The attending writes “decreased renal function, consult nephrologist.” The nephrologist determines the presence of acute renal failure, coders can code the acute renal failure as no documentation by the attending provider conflicts the diagnosis. The attending merely identified that renal function was decreased but did not provide a diagnosis. In this case, the attending remained silent but did not contradict the consultant, allowing us to document diagnoses based upon the consultant’s documentation.

When ordering a consult, attending physicians need to read the consulting physician’s documentation and indicate agreement to the assessment when appropriate. If the attending provider disagrees, he or she should indicate such and provide the appropriate diagnosis for the patient.

The Coding Clinic mentioned earlier states:

“code assignment may be based on other providers’ (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 providers, is appropriate for the basis code assignment.” (Emphasis added.)

Editor’s Note: Sharme Brodie RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.