A consult documents “history of DVT,” while the attending’s problem…

Question

A consult documents “history of DVT,” while the attending’s problem list lists “acute DVT” during the same inpatient stay. What is the coder’s best action?

Accepted Answer

Resolve the acuity conflict with the attending before choosing acute versus history-of codes — “Had a clot once” and “has a clot now” live in different code neighborhoods. When consult and attending disagree on acuity, get the attending to settle it before you pick a family.

Answer

Code acute DVT because problem lists always override consult notes

Answer

Code history of DVT only because consult specialists are more accurate

Answer

Code both acute DVT and history of DVT for the same site and episode

A consult documents “history of DVT,” while the attending’s problem list lists “acute DVT” during the same inpatient stay. What is the coder’s best action?

Short Explanation

Full Explanation