Q&A: More questions from the mailbox

Hi everyone, a few members of the ACDIS advisory board weighed in on some questions sent in by our membership. I’m finally getting around to posting these here in CDI Blog. Keep checking back for updates!

Brian

Q: We have been educated by our coding staff not to use the residents’ notes except as a guideline. They have said that they can only code the record from the actual attending documentation. We try to get physicians to co-sign the resident notes, and sometimes they do and sometimes they don’t. Are other institutions coding right from residents’ notes, or are they also required to have the note cosigned?

Gloryanne Bryant: Keep in mind that the PATH (Physician at Teaching Hospital) rules do require attending physician documentation as you’ve stated, but this requirement is for CPT E&M visit coding only. For inpatient hospital diagnosis coding, in my discussions of this with Nelly Leon-Chisen of the American Hospital Association, we can use the resident’s notes for inpatient hospital coding.

Colleen Garry: If the attending disagrees with other’s notes then you should take the attending opinion. I do not understand why any facility would not take residents’ notes, because residents are doctors (licensed and treating with supervision). I would not code from a medical student’s note without at least a co-sign.

I encourage you to continue to develop relationships with your coding department as I feel there is an opportunity for compromise. Your approach is a bit conservative in my mind. I would argue this places unrealistic expectations of the attending physician.

A brief note from the attending that states, “I have seen and assessed the patient, evaluated and discussed the care with the team, and concur,” and adds additional findings (if any) with a signature and a dated entry, should be enough.

Tamara Hicks: According to coding guidelines, a provider is defined as any individual who is legally accountable for establishing a diagnosis. Residents are legally accountable for this. Now, if the diagnosis is in direct conflict with an attending physician’s diagnosis, then you absolutely should go with the attending.

You may also have difficulty having attending physicians co-sign notes because they are not able to bill for resident’s notes if they do not indicate their participation in the care of the patient.

Robert Gold: As stated by several of the previous respondents, residents are physicians, they are licensed, they do this for a living while they are learning. When the attending disagrees-or a consulting attending-that person trumps the resident.

Now, disagreeing is different than using alternative words for the same condition. If the attending calls something “urosepsis” and the resident has documented “sepsis from acute pyelonephritis,” the resident is being more specific regarding the same disease. But if the resident calls an infiltrate on a chest x-ray pneumonia and the cardiologist says that the infiltrate is pleural effusion, that is a disagreement.

To be sure, specialties will look at a patient through different glasses and the cardiology resident may talk about the patient’s heart failure and pleural effusion while the pulmonology resident talks about pneumonia. Then it’s time to see if both diagnoses exist.

Editor’s note: The ACDIS Advisory Board answered these questions in December 2008. Should you have any questions for the current advisory board, please email ACDIS Editor Linnea Archibald (larchibald@acdis.org).