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AHA Coding Clinic® for ICD-9 - 2004 Issue 1; Ask the Editor

Physician Query

Please provide clarification regarding the appropriateness of code assignments based on the documentation in the medical record by a physician other than the attending physician. Previously published Coding Clinic advice has allowed using documentation from the anesthesia report. Our coders have interpreted that the lack of contrary documentation from the attending can be perceived as concurrence with the anesthesiologist. We have recently been advised that we cannot use a consultant’s note without “confirmation” from the attending physician. Our coders tell us that it is operationally impossible to confirm every single diagnosis or condition that the consultant writes. Of course, if there is conflicting information, we will query the attending physician for clarification. Can you comment on whether our interpretation of coding instructions is correct? ...

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