Diabetic Query/Suggestions

ddouthitddouthit
in CDI Talk Archive
Does anyone have a diabetic/manifestation query or suggestions for format of query that they would be willing to share?


Thanks,

Dorie Douthit RHIT,CCS

Comments

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    This is a DRAFT I just wrote ----still very much a DRAFT and not
    complete.

    I plan to include some basic definitions, seek MD approval, and so
    forth soon.....if you revise or improve this, please post back to our
    message board.


    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    evanspx@sutterhealth.org
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I have been leery of creating a query that lists manifestations and asks if they are appropriate. I am more comfortable looking for documentation of a likely diabetic manifestation (ex: neuropathy), and then querying for an underlying condition (diabetes) to capture the link.
    I'll be interested to see what other hospitals are doing.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404


  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    In that case, a query such as the attached may be useful.

    I think the linkage is so compelling between DM and other commonly-known
    consequences that is appropriate to fashion a query listing the common
    diabetic consequences taking care to provide a choice for 'disagree' -
    'unable to determine' and so forth. The challenge with DM is multiple
    Axes of classification, control and consequences - it is difficult to
    fashion a query fitting on only one page.

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    evanspx@sutterhealth.org

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I think my discomfort stems from wanting to be very careful to make sure that our queries do not appear to be asking for a dx that there are really no indicators for. Our queries are a part of the permanent record and I think our legal team tends to error on the side of caution.
    So, for instance, if there was a dx of neuropathy in a diabetic patient. I would hesitate to place a query asking for manifestations of diabetes with a list of all the possible manifestations. I would prefer to simply address the neuropathy and get that link established. I would worry that upon outside review it could appear that I was attempting to get the MD to diagnose additional manifestations that there is no indication of in the record.
    I am not suggesting that the other way is wrong/unethical, just expressing the way I am most comfortable getting the information I need into the record.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404


  • sharon.colesharon.cole
    edited May 2016
    Is my hospital the only one that does not keep their queries as a permanent part of the record??? I really would prefer to have them be, but our HIM director does not want the queries to be part of the record.

    Sharon Cole, RN, CCDS
    Providence Health Center
    Case Management Dept
    254.751.4256
    srcole@phn-waco.org

  • Linda_RhodesLinda_Rhodes
    edited May 2016
    We do not keep CDI queries as a permanent part of the legal record. They are stored in 3MCDIS (which is discoverable). Coding queries are a permanent part of the record.


    Linda Rhodes RN, BSN, CCDS
    Manager Clinical Documentation Improvement
    New Hanover Regional Medical Center
    Wilmington, North Carolina
    Office # 910-815-5544
    Cell " 910-777-8344
    e-mail : linda.rhodes@nhrmc.org
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I think its split at this point. All our queries (concurrent and retrospective, CDI and coding) are a permanent part of the record.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404


  • tpeytontpeyton
    edited May 2016
    ours are not part of the permanent medical record. If our coders query for some reason then it is kept as part of the medical record.

    Tracy M Peyton RN, CCDS
    Bradford Regional Medical Center
    Upper Allegany Health Systems
    116 Interstate Parkway
    Bradford, PA 16701
    814-558-0406

  • ggoodman@virginiahospitalcenter.comggoodman@virginiahospitalcenter.com
    edited May 2016
    Our Queries are not a part of the permanent record. But we do keep them in our office in case we ever need them.

    Greta Goodman
    Clinical Documentation Improvement Specialist
    Health Information Management
    Virginia Hospital Center
    1701 North George Mason Drive
    Arlington, VA 22205
    703-558-5336
    ggoodman@virginiahospitalcenter.com

  • robert.hodges2robert.hodges2
    I agree with you Katy. In the case you have below I'd send a "signs and symptoms" query and ask for the underlying cause of the neuropathy. You certainly can't presume the link.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited May 2016
    See page 14 of the 2010 Benchmarking Query Report:
    Figure 23: Are your query forms part of the patient's permanent medical record?
    23% Yes
    29% No, but they are archived as administrative information
    33% No
    10% Some are a part of the record and some are not
    1% Don't know
    4% Other

    Don

  • sharon.colesharon.cole
    edited May 2016
    You are the second person who responded saying that only the coders' queries are kept as part of the medical record. Why is that, what's the difference?
    Thanks,

    Sharon Cole, RN, CCDS
    Providence Health Center
    Case Management Dept
    254.751.4256
    srcole@phn-waco.org

  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited May 2016
    I'll offer our perspective, as we are the same.
    It is not who presents the query, but when the query is submitted.
    The post-discharge query is the final word of the attending, while concurrent queries are not. With concurrent documentation, we are looking for & hoping to see a documentation trend in the record as much better than a single response. Depending on the question, might well need to query at discharge if there is only the one response.

    Don

    Donald A. Butler, RN, BSN
    Manager, Clinical Documentation
    Vidant Medical Center, Greenville NC
    DButler@vidanthealth.com ( mailto:mDButler@vidanthealth.com )


  • mdomineseymdominesey
    edited May 2016
    The general guidance from AHIMA and others is to make the concurrent query part of the permanent medical record. The reasoning is that it can help justify the decision-making of the physician and supports the interdisciplinary nature of the care provided. Also, we CDI's are pretty good at laying out the reasoning and clinical indicators for our queries.

    Make them compliant (non-leading) and you will be ok!

    Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
    Sr. Clinical Documentation Improvement Specialist
    Sibley Memorial Hospital

    Information Technology
    5255 Loughboro Rd NW
    Washington DC, 20016-2695

    W: 202.660.6782
    F: 202.537.4477


    http://www.sibley.org


  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016


    An assumption would be stating the pt has DOES neuropathy due to DM - a compliant query asking MD to state if any neuropathy present and if so, to indicate any linkage is not an assumption. The term assumption has many negative connotations.



    I am still working on the attached form - if any of you make any improvements, please post back - the challenges with DM are complex and multiple. I need to revise sections pertaining to neuropathy and ulcer - very difficult to create a one page form for DM. Possible responses include:



    Chronic Complications None Present Unable to Determine





    At my facility, all queries are a permanent part of the record, are vetted by a medical subject matter expert, and reviewed by Compliant.







    Type of DM

    Control of DM & Diabetic Consequences

    Type I

    Type II

    Secondary $B"*(J Etiology: Indicate below

    Steroids

    Post Surgical

    Cystic Fibrosis

    Cushing$B!G(Js

    Neoplasm of Pancreas

    Hematochromosis

    Surgical Absence of Pancreas

    Other: ________________________

    Cannot be Clinically Determined

    Disagree: No DM Present

    Control

    Controlled Uncontrolled $B!H(JUncontrolled$B!I(J diabetes has random blood glucoses over 250 mg/dL or Hgb A1C > 7.0.$B!I(J

    Acute Metabolic Consequences None Present Unable to Determine

    DKA - Blood Glucose 300-600 and/or spilling ketones into urine with ketonemia & acidosis

    Hyperosmolarity - Blood Glucose > 600 w/o significant ketosis

    Diabetic Coma

    Other ______________________

    Chronic Complications None Present Unable to Determine

    Diabetic Nephropathy

    Diabetic Retinopathy

    Diabetic Neuropathy $B"*(JType: Central Peripheral Autonomic

    If Ulcer present, indicate if etiology of Ulcer is due to:

    Diabetic Neuropathy Pressure - Not Diabetic

    Arteriosclerosis Due to DM Arteriosclerosis Not Associated with DM

    Diabetic Osteomyelitis

    Other Consequence(s) of DM - state: ____________________________________







    Paul Evans, RHIA, CCS, CCS-P, CCDS



    Supervisor, Clinical Documentation Integrity, Quality Department

    California Pacific Medical Center

    2351 Clay #243

    San Francisco, CA 94115

    Cell: 415.637.9002

    Fax: 415.600.1325

    Ofc: 415.600.3739

    evanspx@sutterhealth.org



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