Cardiology Question for the Week of December 15, 2025

Question:

Is it permissible to code from documentation from a consultant as long as it’s not conflicting with the attending physician’s documentation? For example, CHF is listed by the attending physician, but the cardiologist states chronic diastolic heart failure. Also, can additional diagnoses be coded from consultant documentation? We are confused if the advice in the 2016 coding clinic that addresses this applies only to pathology, radiology, and lab results, or if it encompasses all other documentation from providers involved in the patient’s care.

Answer:

Yes — under inpatient coding guidelines, it is permissible to code diagnoses from consultant documentation, as long as the attending physician does not provide conflicting information.

Per AHA Coding Clinic (ICD-10-CM), First Quarter 2014, inpatient code assignment may be based on documentation from any licensed provider involved in the patient’s direct care, including consultants, residents, and specialists, unless the attending physician contradicts the diagnosis.

This rule is specific to inpatient coding and differs from outpatient coding requirements, which require the treating provider’s documentation.

According to CMS (Medicare/Medicaid) inpatient guidance:

• If the attending does not mention a consultant’s diagnosis at all, this is not considered a conflict, and the consultant’s diagnosis may be coded when clinically relevant.