Question: I'm an inpatient coder at a large hospital. I am new, so not quite sure how to deal with this situation.
After CDI has done their initial review on a chart, did some early queries and received answers back, BUT as the patient's hospital stay continued on, other doctors specified the dx differently, or it changed since the query was answered...and CDI for some reason never reviewed the chart again (they were done with it??), what do we do here? I'm *assuming* we code to the most current dx? Or what was in the d/c summary.
For example:
Patient had a 20 day stay. CDI queries for stage of CKD. Physician at the time answers CKD 3. THEN, as the stay goes on, if multiple doctors or specialties see the patient, we're back to seeing CKD 3 or CKD 4 alternating through the progress notes. D/C summary ends up stating CKD 4. Do you stick to the CKD 3 from way earlier in the stay? Or would you have to query again? Because it's not up to us coders to look at the lab results/GFR to figure out the stage of CKD.
Another example:
Patient had a 15 day stay. Around day 2, CDI queries for respiratory failure type. Physician answers Chronic Resp Failure. Then, later on in the stay, another doctor documents acute on chronic. If they in fact did develop an acute phase after the query, I'm assuming for this example, I'd code acute on chronic resp failure, with a POA of N? If that is the correct answer, it just seems odd that there's this official/answered query in the medical record, and I end up having a different code. I hope this makes sense.
After CDI has done their initial review on a chart, did some early queries and received answers back, BUT as the patient's hospital stay continued on, other doctors specified the dx differently, or it changed since the query was answered...and CDI for some reason never reviewed the chart again (they were done with it??), what do we do here? I'm *assuming* we code to the most current dx? Or what was in the d/c summary.
For example:
Patient had a 20 day stay. CDI queries for stage of CKD. Physician at the time answers CKD 3. THEN, as the stay goes on, if multiple doctors or specialties see the patient, we're back to seeing CKD 3 or CKD 4 alternating through the progress notes. D/C summary ends up stating CKD 4. Do you stick to the CKD 3 from way earlier in the stay? Or would you have to query again? Because it's not up to us coders to look at the lab results/GFR to figure out the stage of CKD.
Another example:
Patient had a 15 day stay. Around day 2, CDI queries for respiratory failure type. Physician answers Chronic Resp Failure. Then, later on in the stay, another doctor documents acute on chronic. If they in fact did develop an acute phase after the query, I'm assuming for this example, I'd code acute on chronic resp failure, with a POA of N? If that is the correct answer, it just seems odd that there's this official/answered query in the medical record, and I end up having a different code. I hope this makes sense.