Q&A: Querying a consultant’s documentation

Q: If nephrology or another consultant notes acute kidney injury (AKI)/acute renal failure (ARF), but the attending is not writing diagnosis, should you query? I was taught to have the attending confirm the diagnosis written by the consultant(s) to validate diagnosis, maintain continuity, and have this noted on the discharge summary. Our administrator told us that it is not necessary for the attending to write the diagnosis if noted by the consultant, but I disagree; I’ve had denials when the attending doesn’t confirm this particular diagnosis or doesn’t include it on discharge summary. Could you please advise?  

A: According to the Official Guidelines for Coding and Reporting, the documentation of a hands-on, treating provider can be used to support code assignment. For example, as you indicate above, if the nephrologist states AKI, and the attending does not offer either a statement of support or an alternative diagnosis, the AKI can indeed be reported.  

As long as there is no conflicting information within the record, the consultant’s diagnosis can be reported. If you are experiencing denials related to this, I would review the record to clinically validate the diagnosis as being present so that you can include evidence of reportability—i.e., was the condition monitored, evaluated, assessed and/or treated?

Organizations must follow coding guidance, including the Official Guidelines for Coding and Reporting and AHA Coding Clinic. However, some organizations choose to interpret this guidance even more conservatively. There are organizations who will not report diagnoses unless verified by the attending, will not report diagnoses documented only by the emergency room physician, or, even, will not report diagnoses unless they are written in the discharge summary.

I believe such policies are self-limiting and should be reconsidered. My advice is if an organization chooses to follow such practices, an organizational wide policy should be communicated to ensure consistency throughout the organization.  

Editor’s note: Laurie L. Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC, the CDI education director at HCPRo and interim director at ACDIS answered this question. Contact her at laurie.prescott@hcpro.com.