Q&A: Who’s the attending physician?

Q: As far as coding guidelines go, the role of the attending physician’s documentation in the medical record and discharge summary are pivotal for correct code assignment. However, our system uses hospitalists which means the physician of record can change during the course of the day or even multiple times per day. How are the coding rules then to be applied with hospitalists?

A: I am going to speak to how Medicare determines who is the attending physician. Medicare determines which physician is the “attending” physician by who documents the discharge summary.

I know that sometimes physicians are unaware of this rule and may not agree with it based on their time spent with the patient, but unfortunately this is how the attending is determined by Medicare.

The Official Guidelines for Coding and Reporting, Section1.B.14, state that “If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient's attending provider should be queried for clarification.”

So, identifying the attending physician is extremely important. There should also be education for the medical staff, CDI team, and the coders, around who the attending is, especially when you have numerous hospitalists that could be rotating shifts.

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.