Leading Query??

dvitalone1dvitalone1
in CDI Talk Archive
I would like your opinion on the following query example. Do you feel it is a leading query?

Now mind you all the required info is on the query.

Additional documentation is requested as appropriate for accurate coding, to enhance continuity of care and to reflect the overall severity of illness and risk of mortality.

There is documentation in the record per the dietitian's assessment of "severe protein calorie malnutrition."
Anthropometrics: Height: 6' 1" / Weight: 135 lb / BMI (Calculated): 17.8 , alb 2.1
Nutrition Concerns: Low BMI, low alb
As Evidenced by: less than or equal to 79% IBW or less than or equal to 84% UBW;BMI less than 19
"Patient had refused Ensure TID but is willing to take milkshakes BID. Continue to monitor and assess"

Based on the clinical indicators above, would you or would you not concur with the dietitian's assessment.

~ I do concur with the dietitian's assessment

~ I do not concur with the dietitian's assessment

~Other

~Unable to determine

Comments

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I think it's ok. We have similar queries when asking for dx in radiology/pathology reports. If you are concerned, you could always just keep the clinical data and dietary dx there and then just ask what is being treated/monitored, giving the appropriate malnutrition dx to choose from.

    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
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    I do not think it is leading as you are asking an MD to comment on language that exists in the record prior to a CDI review.


    Given the recent issues in the industry regarding the billing of malnutrition, we have used wording below in similar situations:


    Example 1. Please review the assessment performed by the RD as dysphagia and significant weight loss is documented by the RD. The Albumin is recorded as 2.9 and Ensure T.I.D. has been ordered. Please comment on these findings and express as a diagnosis, if appropriate. Based on your professional judgment, can you further clarify in the clinical significance that these findings represent, if any, and its severity?

    Example 2. Per the H&P, the patient with cancer, AIDS, and multiple decubitus ulcers has poor oral intake with a BMI of 18 and albumin of 2.2 and protein shakes have been ordered as supplements. Please comment on these findings and express as a diagnosis, if appropriate.

    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
  • ddouthitddouthit
    edited May 2016
    I like Katy's idea regarding listing clinical indicators and then giving choices for appropriate malnutrition.
    This gives physician opportunity to provide physician clinical judgment without just one malnutrition choice. If he were to choose doesn't concur, you could potentially lose your malnutrition all together.

    Dorie Douthit, RHIT,CCS
  • dvitalone1dvitalone1
    edited May 2016
    We have been doing this and we are losing the cc of malnutrition when we ask for specificity. For some reason is seems that the physicians do not like documenting severe protein calorie malnutrition even though the clinical indicators are there and dietary's assessment reflects. We are getting mod or mild malnutrition when we query that the dieticians assessment indicate severe protein calorie malnutrition. We are trying to compose of a different format query and came up with the "I concur with dietary's assessment" or "I do not concur"
    Thank you to those who have given their input.


    DAWN M. VITALONE, RN
    Clinical Documentation Improvement Specialist
    Community Hospital
    Munster, IN
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    True. At minimum it would be beneficial to ask for a more appropriate dx if they do not agree.

    Ex: I do not concur with the dietitian's assessment
    -More appropriate diagnosis ___________________________________________________

    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
  • ssalinasssalinas
    edited May 2016
    The good news is that mild and moderate malnutrition WILL BE a CC as of October 1. They have been added to the CC list effective that date.

    Sharon Salinas, CCS
    Barlow Respiratory Hospital
    213-250-4200 Extension 3336
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Some suggestions for MD response(s):

    Please indicate with your initial the significance of this documentation and laboratory values.

    _____No evident of undernutrition _____ Overweight
    _____Mild Malnutrition _____ Obese
    _____Moderate Malnutrition _____ Morbid Obesity
    _____Severe Malnutrition
    _____Other _____ This/These were Present on Admission
    _____Cannot be clinically determined


    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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