If the final discharge diagnosis is abdominal pain with unclear etiology but GI consult notes indicate recurrent colitis, what action is appropriate for the CDI?

• A. Query for clarification due to conflicting documentation
• B. Accept the GI notes as definitive
• C. Document the conflict without querying
• D. Proceed with coding without clarification

Answer: (A)

When documentation doesn’t line up, the right move is to query the physician for clarification to reconcile conflicting information. Here, the final discharge diagnosis is abdominal pain with unclear etiology, but GI consult notes mention recurrent colitis. A clarification query helps determine whether recurrent colitis is a definite diagnosis, a comorbidity to be coded, or merely a differential that needs to be ruled out, and it ensures the final codes accurately reflect what was truly diagnosed and treated.

Accepting the GI notes as definitive would ignore the inconsistency between the discharge diagnosis and the consult. Simply documenting the conflict without querying leaves the discrepancy unresolved and risks inaccurate coding. Proceeding to code without clarification could misrepresent the patient’s condition and run afoul of documentation guidelines.