A consulting nephrologist documents and manages acute kidney injury during an inpatient stay. The attending’s notes reference the consult. How should the facility coder treat the consultant’s documented condition?
Select an answer to reveal the explanation.
Short Explanation
Consult notes are part of the hospital record story. If the consultant documents a condition that was evaluated or treated this stay and it meets reporting rules, it belongs in the abstract. You do not need the consultant’s office bill to make that call.
Full Explanation
Conditions documented by consulting providers may be coded for the facility inpatient stay when they meet Official Guidelines and UHDDS-like secondary diagnosis reporting criteria (for example, evaluated, treated, monitored, or otherwise clinically significant this encounter). Consultant documentation is not ignored simply because the writer is not the attending, nor does it automatically become principal diagnosis.