The coders are telling me that they cannot use a comorbid condition that is only documented by a physician consultant and not by our rehab doctors.  Specifically, a cardiologist stated in 2 of his progress notes that the patient had “acute on chronic CHF” but the rehab doctors did not mention it, therefore the coders cannot code it.  Would you know if this is the case?

(Lou is Rehab)

ANY physician documentation can be utilized as long as it does not CONFLICT with the attending.  A query would need to be performed if there were conflicts.  If the condition is treated, impacts treatment, extends the length of stay or utilizes resources and is documented by a physician as such it may be reported.