Diagnosis Justification

tkreiling

Any suggestions or templates out there for furhter clarifying from a phyisician how they may have came to a particular diagnosis? Would like some sort of form that they physician would wirte on to note any clinical indicators they found that justified to them to make a particular diagnosis. I am trying to think of some way to ask or write to the physician without appearing that I am questioning the physicians diagnosis but still need to have a strong medical record that supports the diagnosis the physician may have wrote. Any help or templates would be greatly appreciated.
Thanks,
Tara

robert.hodges2

I don't have a query for that, but I know what you're talking about. It's very delicate to approach a provider about asking them to further justify their diagnosis. Now having said that, would a question to ask them to provide further documentation to support their diagnosis so you can accurately capture SOI/ROM be appropriate? That way you are less questioning the diagnosis than asking for more documentation to support it.

Of course, if you have a physician advisor you may want to ask for their thoughts on it as well and get their suggestions on how to approach it.

Just thinking out loud here.

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
 
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
 
"We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley

don.cdi.rn@gmail.com

This was a topic that I believe was touched on several times at the
conference. It is also one that we are thinking through and working
toward addressing head on.

Warning, long response ahead.

One of the concepts that Dr Kennedy addressed during the physician
advisor pre-conference was some 'new' variations of the reasons for
query as outlined in the AHIMA brief, which states (delineated by
'========')

========
"Providers should be queried whenever there is conflicting, ambiguous,
or incomplete information in the health record regarding any significant
reportable condition or procedure"

"Healthcare entities could consider a policy in which queries may be
appropriate when documentation in the patient’s record fails to meet
one of the following five criteria:
*Legibility. This might include an illegible handwritten entry in the
provider’s progress notes, and
the reader cannot determine the provider’s assessment on the date of
discharge.
*Completeness. This might include a report indicating abnormal test
results without notation of
the clinical significance of these results (e.g., an x-ray shows a
compression fracture of lumbar
vertebrae in a patient with osteoporosis and no evidence of injury).
*Clarity. This might include patient diagnosis noted without statement
of a cause or suspected
cause (e.g., the patient is admitted with abdominal pain, fever, and
chest pain and no underlying
cause or suspected cause is documented).
*Consistency. This might include a disagreement between two or more
treating providers with
respect to a diagnosis (e.g., the patient presents with shortness of
breath. The pulmonologist
documents pneumonia as the cause, and the attending documents
congestive heart failure as the
cause).
*Precision. This might include an instance where clinical reports and
clinical condition suggest a
more specific diagnosis than is documented (e.g., congestive heart
failure is documented when an
echocardiogram and the patient’s documented clinical condition on
admission suggest acute or
chronic diastolic congestive heart failure)."
========

Dr Kennedy specifically discussed as a new element that of "unreliable"
diagnosis, i.e., one that is not clinically supported. He also
suggested a new variation of the concept of consistency, which would be
based on the frequency of a diagnosis being mentioned.

Dr Kennedy also referenced a model (not new, but very useful to really
reflect upon and apply to one's CDI practice) -- M.U.S.I.C. This model
may be useful as you are trying to approach that provider to provide
additional documentation underlying a particular diagnosis.
Essentially, this model tries to drill through layers of due to, caused
by & demonstrated by.

Manifestation -- sepsis, heart failure, chest pain, angina
Underlying Pathology -- UTI, alcoholic cardiomyopathy, GERD, coronary
atherosclerosis
Severity or Specificity -- accelerated HTN, severe sepsis, uncontrolled
diabetes
Instigating or Precipitating cause -- indwelling foley cath, NSAID use,
CO poisoning
Complications or Consequences -- septic shock, diabetic neuropathy

Something else that was discussed during the preconference, and which
has been discussed on CDI Talk previously, is to develop (with
partnership of your medical staff) are standard definitions of key
diagnosis or conditions. This would help to point toward specific items
that may be missing in the documentation to support the diagnosis.

Don

tkreiling

Thanks for your responses. I think we are going to work on getting some process in place for these types of situations and questions. Unfortunately, we do not have a physician advisor to take this cases to.

Thanks,
Tara

robert.hodges2

Just wondering, do you have a favorite doc that you could ask to do a peer review? I've been doing that lately in cases where the documentation isn't supporting the diagnosis, be it under documentation or over documentation. I don't have a physician advisor either, but I do have some doc's I can go to ask that informal question.

Another option may be to go to quality and see if they have any input. Definitely an opportunity for provider education though.

Good luck!

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
 
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
 
"We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley