What action should a CDS take if a diagnosis made by a specialist conflicts with the attending physician’s documentation?

• A. Code GI bleed as documented.
• B. Ignore the query.
• C. Utilize the clarification provided by the attending physician for coding.
• D. Code the diagnosis made by the specialist as he would know more about the bleed.

Answer: (C)

When faced with conflicting diagnoses between a specialist and an attending physician, the most appropriate action for a Clinical Documentation Specialist (CDS) is to utilize the clarification provided by the attending physician for coding. The attending physician is typically responsible for the overall care of the patient and has the final say in the documentation that reflects the patient's condition.

In scenarios where disagreements arise, it is vital for the CDS to rely on the attending physician's documentation because it must accurately reflect the patient's status and bear the provider's signature for compliance and legal purposes. This ensures that the documentation aligns with the physician's clinical judgment and the complete medical record.

While documenting the diagnosis made by the specialist may seem reasonable, it could lead to inconsistencies in the patient’s record if it lacks support from the attending physician. The CDS's role includes ensuring that documentation is comprehensive, clear, and compliant with regulations and standards. By following the attending physician's clarification, the CDS maintains the integrity of the medical record and upholds coding accuracy.