Q&A: Conflicting documentation between the attending and consultants

CDI Strategies - Volume 16, Issue 16

Q: I had a recent case where the nephrologist and cardiologist both documented hypertensive (HTN) emergency, but the attending documented HTN urgency. The attending was correct based on clinical indicators. Does that mean I don't have to query the attending and can just take his word since he has the final say?

Also, in a similar scenario, I recently queried a nephrologist on sepsis since he was the only one saying sepsis with systemic inflammatory response syndrome (SIRS), and I wanted to make sure to rule sepsis out completely in the documentation. Could I have ignored that documentation and not to queried for sepsis since the attending documented SIRS without infection?

A: These are great questions! I am going to separate these scenarios and go through the process for each one.

In the case of hypertensive emergency versus HTN urgency, it looks like you do have conflicting documentation, and a clarification query for conflicting documentation would be warranted in this case.

Coding Clinic, First Quarter 2014, p. 11, advises, “Code assignment may be based on other physician (e.g., consulting physicians, residents, anesthesiologist, etc.) documentation as long as there is no conflicting information from the attending physician.” If conflicting documentation does exist, query the attending provider.

Additionally, coders cannot omit codes based on clinical criteria, as advised in Coding Clinic, Fourth Quarter 2017, p. 110, under the heading “Omitting ICD-10-CM codes.”

Severe cases of hypertension are defined as a blood pressure (BP) of more than 180/120 mm Hg and are further categorized as hypertensive emergencies or urgencies. Hypertensive emergencies are characterized by evidence of impending or progressive target organ dysfunction, whereas hypertensive urgencies are those situations without progressive target organ dysfunction.

Hypertensive urgency typically does not require an inpatient level of care, but hypertensive emergency usually does because the patient shows some form of organ damage. Symptoms of hypertensive emergency would include but are not limited to chest pain, dyspnea, shortness of breath, blurred vision, confusion, numbness/weakness, or impaired renal function.

In the scenario you described, the patient did have a cardiology and nephrology consult. This would indicate that the patient presented with possible cardio and/or renal symptoms related to hypertension. Both the cardiologist and nephrologist are clinical specialists in their respective arenas. With both specialists diagnosing and documenting hypertensive emergency, the question (query) to the primary provider would be appropriate. Hypertensive emergency is a comorbid condition (CC), but hypertensive urgency is not. If appropriate, the hypertensive emergency would better define the resource consumption used for this patient.

Your second scenario also represents conflicting documentation between sepsis and non-infectious SIRS as the consulting service is stating sepsis and the primary service is stating non-infectious SIRS. The Official Guidelines for Coding and Reporting, section II.C.6, “Sepsis and severe sepsis associated with a noninfectious process (condition),” states,

In some cases, a noninfectious process (condition) such as trauma, may lead to an infection which can result in sepsis or severe sepsis. If sepsis or severe sepsis is documented as associated with a noninfectious condition, such as a burn or serious injury, and this condition meets the definition for principal diagnosis, the code for the noninfectious condition should be sequenced first, followed by the code for the resulting infection.

Sepsis is a highly audited and clinically denied diagnosis, and coders cannot selectively omit a diagnosis based on clinical criteria, as stated in the Coding Clinic advice above. If a diagnosis (condition) required clinical evaluation, therapeutic treatment, diagnostic procedures, extended the length of stay, or increased nursing care and/or monitoring, the condition would be coded. The primary provider would be queried in this case for conflicting documentation to either specifically rule out the sepsis diagnosis after study in the progress notes and/or discharge summary or better support the sepsis diagnosis with clinical indicators and treatment.

Bottom line advice is, when in doubt, send the query out.

Editor’s note: Kim Conner, BSN, CCDS, CCDS-O, CDI education specialist for ACDIS/HCPro based in Middleton, Massachusetts, answered this question. Contact her at kconner@hcpro.com

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