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Q&A: Determining when coders should query for definitive diagnoses

Q: We are struggling with coders querying certain diagnosis because they feel there is conflicting documentation in the record, and then we are “losing” that diagnosis. For example, the physician documents acute respiratory failure a couple of times and dyspnea in the discharge summary and the coders query confirming whether respiratory failure was ruled in or out. Same thing with respiratory failure and hypoxia. Same with bacteremia and sepsis (that’s a little stickier) and delirium and encephalopathy. Can a symptom be conflicting with a diagnosis? I’d love to have ACDIS’ opinion on this.

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