November 28, 2016

Controversial: Attending Physicians Denying Responsibility?

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Unfortunately, I have been too busy of late to say much about the two new Coding Clinic editions, which came out nearly at the same time, due to being in the midst of preparing for the new ICD-10 codes that became effective Oct. 1. Certainly there are many that merit further study and conversation, but one in particular stands out: the Coding Clinic published for the third quarter of 2016 (specifically, see page 26):

“It is the responsibility of the attending physician to gather and collate all of the findings from the consultants and other providers involved in the care of the patient. The plan of care is based on the attending physician’s evaluation, interpretation, and collation of all the findings (i.e., pathology, radiology, and laboratory results).”

One of the most common questions I get from new clinical documentation specialists (CDSs) or CDSs in new clinical documentation improvement (CDI) programs involves what to do when the physician says that he or she cannot respond to a query about a diagnosis made by a consulting provider, a query made by a partner who was responsible for the care on a different day, or a query based on a finding within the pathologist’s note or laboratory findings.

When faced with this in the past, there was little we could do, and by “little” I mean creative education, pleading, begging, and in some extreme cases, escalating to a physician advisor or administration. This Coding Clinic gives us one more piece of information to leverage in our conversation with the attending physician, and certainly this will become a mainstay of physician education regarding CDI programs.

Looking closer at the entry, it does in fact say that the attending physician is responsible for all of the findings of the consultants and other providers involved in the care of the patient. I want to emphasize the word “all” here. Not some, not those parts he or she is comfortable with, not just what happened today or even this week – all. The entry does not give any qualifying circumstances or exceptions.  

Does this mean that the attending has to agree with the consultants or other service providers? Certainly not. The attending physician (after having evaluated further diagnostic findings and the patient’s response to treatments) may in fact present an alternative diagnosis or simply rule out a diagnosis made earlier in the stay. If the patient’s symptoms and/or conditions have resolved and/or earlier treatment has been discontinued, the physician may be at a bit of a disadvantage, but he/she is certainly qualified to review the diagnostic findings, previous physical assessments, and responses to treatment – and to agree or disagree with an earlier physician’s diagnosis on a resolved condition.

As a matter of fact, the above Coding Clinic excerpt seems to be stating very emphatically that performing this task is, in fact, the job of the attending provider. While this is not really a new concept, things have gotten bad enough in actual practice that Coding Clinic clearly felt compelled to state it in print. I am going to infer that things have must have gotten even worse than I previously thought for this to have occurred.  

How bad is it? In the new age of team medicine and shared responsibility, we often run into real-world situations for which it would seem by the documentation in the record (and the responses from providers) that many of our acute inpatient hospital patients don’t have any real diagnoses – and where we think maybe they do, nobody is responsible for writing the diagnoses in the record and/or answering any clarification questions! Since we know that to be factually untrue, Coding Clinic appears to have endeavored to remind the attending physicians of their responsibility in this regard.

To take it one step further, this Coding Clinic entry goes on to note that the attending physician carries the ultimate responsibility not only for the diagnoses of other providers, but also for the treatment plan, as well as being obligated to address abnormal findings with respect to pathology, radiology, and lab work.

Does that mean the physician has to have a diagnosis associated with every abnormal finding? Certainly not. What is required is either a diagnosis or (where appropriate or when queried) the documentation indicating that the findings are not clinically significant. 

This is not exactly the sort of thing that is enforceable as law or rule, or even as a policy, necessarily. It is by definition a guideline. However, this entry written here in black and white is a valuable educational tool and reference indicating for what the attending physician is responsible. I would start by flagging this one as a note to your physician advisors or champions (if you have one).

Pick your battles wisely.
Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Allen R. Frady, RN, BSN, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer

With 20 years in healthcare, Allen R. Frady provides clients assistance in the areas of documentation, program implementation and compliance. His background includes critical care nursing, coding, auditing, utilization review, and documentation improvement.