Querying the Attending Physician to Resolve Documentation Conflicts for Accurate ICD-10-CM Coding.

When the chart isn’t crystal clear, who gets to decide the code?

Let me ask you a quick question: in a busy hospital day, you spot a mismatch between what the chart says and what the patient really needs. It happens more often than you’d think. The fix isn’t about guessing or sticking to a single person’s gut feeling. It’s about getting the record right, with what really happened and why it happened. And that often means reaching out to the one person who can confirm the clinical story—the attending physician.

This is a core principle in ICD-10-CM coding: when documentation conflicts, the safest, most accurate path is to query the attending physician. Why? Because the physician has the most complete picture of the patient’s condition, the services delivered, and the clinical reasoning behind decisions. Their input can clear up ambiguities and ensure the codes reflect the true medical situation. It’s not about blaming anyone or trying to score a perfect chart; it’s about integrity, compliance, and patient care.

Let’s unpack what this means in practical terms. We’ll walk through the why, the how, and the real-world impact of asking for physician clarification when documentation isn’t lining up with coding needs.

Why the attending physician matters

Think of coding as translating a patient’s medical story into standardized alphanumeric labels. Those labels—ICD-10-CM codes—must map accurately to the patient’s condition, the severity, the treatments given, and the intent of services. If the narrative in the chart is fuzzy, codes can easily misrepresent what happened. That can lead to denied claims, audit flags, or, worse, an inaccurate picture of the patient’s health for that encounter.

The attending physician is the primary source of truth for the clinical story. They know:

• The exact diagnosis or condition as they saw it.

• The rationale for treatments, tests, and procedures.

• Any uncertainties or evolving assessments during the encounter.

• The intended level of care and the patient’s response.

When there’s a discrepancy, a well-phrased query helps align the record with the reality of the patient’s condition. It’s collaboration in action, not confrontation.

What not to do when documentation conflicts

To keep this patient-centered process intact, there are a couple of paths you want to avoid:

• Relying solely on staff observations: Nurses and other team members provide crucial, front-line insights, but a chart can’t be correctly coded on observations alone. A higher-level clinical decision or final diagnosis often rests with the physician.

• Leaving it to a single coder’s interpretation: A coder’s expertise is essential, but the medical record must reflect the clinician’s intent and the documented rationale. If you code from an interpretation without physician input, you risk inaccuracies.

• Adhering rigidly to one’s own judgment: Documentation is the anchor for coding. When it’s ambiguous, the safest move is to seek clarification rather than assume.

How to approach a physician query—without friction

Okay, you’ve found a conflict. Now what? The goal is a precise, fully supported code set. Here’s a practical approach that keeps communication respectful, efficient, and compliant:

• Identify the ambiguities clearly: Note exactly what in the record is unclear. Is it the diagnosis, the stage or severity, the exact condition, or the coded service? The more precise you are, the quicker the physician can respond.

• Be concise and professional: A physician query should be a focused question, not a paragraph-long debate. State the issue, reference the supporting chart data, and ask for confirmation or additional detail.

• Provide options or context when helpful: If there are plausible interpretations, present them briefly and indicate which you believe aligns with current guidelines. This helps the physician zero in faster.

• Link to guidelines when possible: Mention relevant ICD-10-CM guidelines or policy references that support the request. It shows you’re following established standards, not just guessing.

• Log and document responses: Keep a tidy trail of queries and answers. This isn’t just for one note—it's part of the medical record and the coding history for the encounter.

• Respect the clinical workflow: Time is precious in a hospital. Frame the query so it can be resolved quickly, perhaps as a targeted question to the attending or a brief consult note.

A simple template can help:

• “On the admission note [date], the diagnosis is listed as [X]. The operative report and imaging suggest [Y] with [Z]. Do you confirm that the primary diagnosis should be [Y] and that [X] is a resolved or ruled-out condition? If not, please specify the final diagnosis to code for this encounter.”

Real-world impact: better codes, better care

When we align the record with the physician’s intent, several things happen that matter beyond the numbers on a bill:

• Accurate reimbursement: Payers rely on precise codes. Clear documentation and physician clarification reduce the risk of denials or downcoding, which helps the hospital and the patient alike.

• Quality and reporting: ICD-10-CM codes feed into hospital quality measures, population health analytics, and performance dashboards. Accurate coding supports meaningful, actionable data.

• Patient safety and continuity of care: A clear, well-supported chart reduces the chance of miscommunication during handoffs. It helps future care teams understand what happened and why.

• Documentation improvement: Regular physician queries become a learning loop. They highlight areas where charting could be clearer in the future, which raises the overall quality of documentation.

Common scenarios where physician input is especially valuable

• Ambiguous diagnoses: The chart might say “probable pneumonia” or “suspected myocardial infarction.” Clarification helps lock in the final diagnosis and the exact coding needed.

• Unclear severity or stage: For examples like sepsis, acute kidney injury, or cancer, knowing the precise level of severity or stage drives the correct codes and the justification for treatments.

• Documentation gaps in services rendered: If a procedure or test is documented, but the indication isn’t, a quick physician check can tie the service to the clinical reason for the encounter.

• Conflicting notes: When progress notes, discharge summaries, and orders seem out of sync, a query can harmonize the record and prevent miscodes.

Keeping the process ethical and compliant

You don’t want the physician query to become a loophole or a backdoor for stretching conclusions. The right approach is to document uncertainties, not to force a diagnosis to fit a preferred code. That’s why the official coding guidelines emphasize clarity, justification, and patient-centered accuracy. If there’s a legitimate ambiguity that changing the diagnosis would misrepresent the patient’s condition, a well-posed query helps preserve integrity.

Practical tips from the trenches

• Use the tools you’ve got: Most electronic health record systems offer structured query templates. Use them to create fast, consistent queries.

• Collaborate, don’t confront: Frame your outreach as a joint effort to get it right, not as a challenge to the physician’s judgment.

• Maintain a steady cadence: Some conflicts are easy to resolve; others take a moment of back-and-forth. Build a routine that respects everyone’s time while safeguarding accuracy.

• Stay current with guidelines: The ICD-10-CM Official Guidelines change over time. A quick refresher keeps your queries grounded in the latest standards.

• Document rationale for the final decision: When you code, note the physician’s confirmation or the documented reason for the final choice. This helps future audits and reviews.

A quick, relatable analogy

Think of coding like translating a story into a universal language. The physician writes the story in clinical terms; you, the coder, translate it into codes that everyone understands—insurance, regulators, and patient care teams included. If the original story has a missing chapter, you don’t guess the plot. You ask the author to fill in the gaps. That author’s answer becomes part of the shared narrative, ensuring everyone reads the same story.

A gentle reminder: collaboration is king

In the end, the right move when documentation conflicts is simple: ask the attending physician for clarification. That single step keeps coding honest, supports accurate reimbursement, and, most importantly, protects the patient’s record. It’s an act of professional stewardship—a small move with big consequences for care continuity and trust in the medical record.

If you’re studying or working in this field, you’ve probably seen how a well-placed query can transform a confusing chart into a coherent, compliant clinical story. And yes, it can feel like you’re threading a careful needle—balancing detail, brevity, and precision. But with practice, a bit of patience, and a collaborative mindset, you’ll make those queries feel almost automatic.

Final thought—the path to clarity isn’t a single hop; it’s a conversation

Documentation isn’t a static thing. It’s a living record that improves when we engage thoughtfully with the people who wrote it. The attending physician isn’t a gatekeeper; they’re the co-author who can confirm the line between “suspected” and “confirmed,” between “rule-out” and “present.” When the chart doesn’t tell the whole story, a respectful, well-targeted query is the most reliable way to keep the record truthful and the care outstanding.

If you’re involved in ICD-10-CM coding, let this be a reminder: the best codes come from a clear, confirmed clinical rationale. And the best way to get there is a collaborative, well-documented dialogue with the physician. It’s not just about getting paid; it’s about honoring the patient’s story with accuracy, fairness, and care.