Q&A: Coding uncertain diagnoses documented by consultants only

Q: If an uncertain diagnosis is only documented by a consultant consistently through the medical record, including in the last progress note, and is left out of the discharge summary, should that diagnosis be coded?

A: Great question. It should be coded only if the attending does not contradict or is silent on the matter.

According to AHA Coding Clinic for ICD-10, First Quarter 2014:

“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.

Documentation is not limited to the face sheet, discharge summary, progress notes, history and physical, or other report(s) designed to capture diagnostic information in the inpatient setting.”

If the patient is covered under Medicare or Medicaid, then CMS has answered the question as well:

“However, the failure of the attending physician to mention a consultant’s diagnosis is not a conflict.

So, if the consultant documents a diagnosis and the attending physician doesn’t mention it at all, it is acceptable to code it.”

Bear in mind, though, that newer advice does indicate that we should compel the attending physician to address these through our education. According to AHA Coding Clinic for ICD-9-CM, Third Quarter 2016, p. 26:

“It is the responsibility of the attending physician to gather and collate all of the findings from consultants and other providers involved in the care of the patient. The plan of care is based on the attending physician’s evaluation, interpretation, and collation of all the findings” … (i.e. pathology, radiology, and laboratory results)

The entry from 2016 makes an interesting response to attending physicians who take the “that ain’t my job” approach to answering queries when they are the attending of record but did not provide care on the date of service in question or hesitate to address diagnoses made by the consults they requested.

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CRC, CDI education specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.