Query Tip: What is Conflicting Documentation? | Health Information Associates

Beth Martilik​, MA, RHIA, CDIP, CCS Assistant Director of Education AHIMA Approved ICD‑10 Trainer and Ambassador Beth Martilik,​ MA, RHIA, CDIP, CCS
Assistant Director of Education
AHIMA Approved ICD‑10 Trainer and Ambassador
Conflicting documentation occurs when health care providers call the same condition different things. When none of the documented conditions are clearly ruled out by the physician, coders may find it necessary to query for the most appropriate diagnosis. Some examples of conflicting documentation may include:

  • Respiratory failure vs respiratory insufficiency
  • Pneumonia vs acute bronchitis
  • Acute renal insufficiency vs acute kidney injury
  • COPD exacerbation vs CHF exacerbation
  • Sepsis vs bacteremia vs urosepsis

It would be up to the attending physician to make the determination which diagnosis is most appropriate based on clinical indicators and his/her professional judgment.

Below is an example of how a physician query to clarify conflicting documentation may be written. Be sure to include relevant clinical indicators that may be used to rule in or rule out the listed diagnoses.

The diagnosis of pneumonia was documented on 11/3 by Physician A
The diagnosis of acute bronchitis was documented on 11/4 by Physician B
The diagnosis of cough was documented as final diagnosis on discharge summary

Clinical Indicators:

*Productive cough, SOB, fever (H&P 11/1)
*WBC 15, CXR negative (H&P 11/1)
*Sputum culture negative (PN 11/3)
*IV antibiotics on admission, discharged on po antibiotic (DS 11/4)

Based on your medical judgment, can you clarify which of these conditions best reflects the etiology of patient’s symptoms?

*Acute bronchitis
*Pneumonia
*Other diagnosis ________________ (specify)
*Unable to determine

 

The information contained in this query advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.

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