Query or don't query.... I had an ER chart, all documentation was consistent with HTN. When getting to final dx on this chart it did have HTN listed but it also had a final dx of UTI. During the visit the patient was given urine test, why I am not sure, I did not think urine micro and culture testing went along with HTN treatment. Final dx for this patient was HTN, treated with Lopressor, and, UTI treated with Cipro there was NO documentation signs, symptom related to having a UTI so possibly this Dx was an incidental finding from the urine testing. I am not educated to read lab results nor can I code from a lab, and from looking at labs for many years, did not look like a positive for UTI.
Question is: Does this chart need documentation to support the UTI dx and treatment? Lead coder says I over analyze the charts and do not need to query for supporting documentation. Is the dx of UTI, and given Cipro ok without documentation or should a query be sent for supporting documentation, If doctor would have documented UTI was an incidental would have been no question.