ICD-9 codes on Queries?

mdomineseymdominesey
in CDI Talk Archive
Just an informal question - does anybody put ICD-9 codes on their query forms?

I have been asked to help a group of physicians determine which diagnosis is a "complication". While we know that 996.xx codes are complication codes, there are other diagnosis that may count against the physician for quality reporting that may not be 996.xx codes. It is a very fine line to keep from leading a physician towards a diagnosis.

Simple question is - how appropriate is it to have the ICD-9 code next to the diagnosis on the query sheets?

Thanks,

Mark



Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
Clinical Documentation Excellence
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
mdominesey@sibley.org

http://www.sibley.org



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Comments

  • robert.hodges2robert.hodges2
    I don't put ICD-9 codes on query sheets because codes change, diagnoses don't. I also remember reading somewhere that they suggest providers not use codes in their notes. Someone else here probably has better information on this than I do.

    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
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    No. I don't include the diagnosis codes. However, I will provide a definition of a code (functional quadriplegia and critical illness myopathy come to mind). For complications, we specifically ask if conditions are a complication of a procedure.

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


  • Unknown
    edited May 2016
    Several years ago I used some ICD-9 codes. I initially thought it would help them to see the specificity we were looking for. Kind of backfired - I quit using them when the physicians started putting down codes but no diagnosis.



    Charlene Thiry RN, BSN, CPC, CCDS
    Clinical Documentation Specialist
    Quality Resources


  • sharon.colesharon.cole
    edited May 2016
    This is how we do it as well.

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

  • mdomineseymdominesey
    edited May 2016
    I guess the problem really is - the physicians want to know which diagnoses in the list of diagnoses provided would be a complication code.... I know all about leading queries and all that, just trying to help them with their request to know what they are choosing so they may know which are complications and which are not. I also think that this is not the way to go and I have been trying to talk them out of this method.

    Thanks for the input,

    Mark



    Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
    Clinical Documentation Excellence
    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
    mdominesey@sibley.org

    http://www.sibley.org


  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Can you just formulate a query asking if the condition is a complication? That makes is pretty clear. I attached an example of one we use.

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


  • robert.hodges2robert.hodges2
    Maybe give them a list of the common CC/MCC's for your facility. I know I have a pocket card on that without the codes and use it as an educational tool. Just a thought.

    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
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