Organization-Wide Definitions

Does anyone have specific, well-vetted definitons for their hospital which define when an MD should apply and document specific or vague diagnoses such as encephalopathy, delirium, acute respiratory failure, acute respiratory insufficiency, sepsis, Acute renal failure, etc.?
I am just curious if having an established definiton within the facility, based on researched data, would help eliminate insurance audit denials where the Insurance MD states that "the patient did not meet criteria for acute respiratory failure". It appears there have been increasing denials for diagnoses written by MDs that are reviewed and $ is taken back.
Any and all viewpoints are welcome!
Thank you.

Comments

  • I think many facilities choose to include definitions in their queries. MD's seem to find this very helpful for the most part. Most of our queries do not include definitions though I would be interested in adding this down the road. The issue with us is that I think it is really important for the physicians to be involved in coming up with the definitions and in general, we do not have this type of support (yet?).
    I think the problem with the idea of creating some sort of documented criteria for diagnoses is that in the end, it really should be the MD's decision when to diagnose/document a dx. They are the one working hands-on with the patient. And there may be circumstances where a patient does/does not meet criteria but the MD still thinks the dx is accurate (or invalid). It is important that the MD be making this decision on an individual basis. This is why we talk a lot about probable/possible diagnoses. Sometimes medicine is a big guessing game and MD's should have room to use their best clinical judgment when making a diagnosis.
    Also, regardless of any definition, the coder is still bound to code what is in the record. So regardless of what the hospital decides defines a particular dx, if the MD chooses to document it, the coder will code it.

    Sepsis is a great example of this. There are pretty well defined criteria for Sepsis (http://www.mdanderson.org/education-and-research/resources-for-professionals/clinical-tools-and-resources/practice-algorithms/clin-management-sepsis-management-adult-web-algorithm.pdf). However, plenty of patients will technically meet criteria (ex: leukocytosis and tachycardia or fever) but an MD does not think they are septic. Maybe they just have a simple UTI or URI? Regardless of the criteria, they should only use this diagnosis if they think the patient is actually septic.

    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

  • There have been several conversations about this before, and there are
    specific organizations that have developed definitions. The typical
    approach seems to be to choose an initial small number of clinical
    conditions and partner with the specialty area that is most closely
    associated. It certainly takes quite a bit of 'buy-in' and physician
    leadership. Also quite helpful is the availability of fairly clear and
    broadly accepted definitions in the literature.

    Off the top of my head, four conditions that have good literature
    statements would include AMI (Universal Definition of Myocardial
    Infarction, Circulation. 2007; 116: 2634-2653
    http://circ.ahajournals.org/content/116/22/2634.full), sepsis
    (article by Dr Levy Intensive Care Med. 2003 Apr;29(4):530-8), acute
    renal (KDIGO), and the recent publication of a consensus statement on
    malnutrition
    (http://www.nutritotal.com.br/diretrizes/files/238--DiretrizJPEN2012.pdf).
    The real challenge to me with these kind of literature resources is the
    opinion and perspective of the specialists at your specific hospital.

    Dr Trey La Charité (ACDIS Advisory Board member, U of TN, Knoxville)
    specifically discussed during a portion of the pre-conference session
    for Physician Advisors. As I recall (and I don't have my notes with me,
    so memory only) he advocated for the creation of organizational
    definitions for conditions. Additionally, he suggested that the
    establishment & use of definitions should provide measurable defense
    against various auditors.

    Don


  • edited May 2016
    I agree with you Katy. Several VA query forms have guidelines and definitions, but it is still up to the provider's clinical judgment and medical decision making to document the diagnosis they are treating. Documentation does help this, but it's a bit different going hands on vs. a chart review.

    When I worked at another hospital we would get denials because the insurance company physician disagreed with the diagnosis as well. Our answer was to have a physician to physician dialog occur. We would always brief our provider as to why it was happening and that they simply had to support their diagnosis. Needless to say, it was highly effective in overturning these denials.

    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
     
    “Patriotism is easy to understand in America; it means looking out for yourself by looking out for your country" Calvin Coolidge

  • Correct me if I am wrong, but haven’t there been plenty of denials where the RAC disagrees with the standard definitions too?
    I am not very involved in our denials but I think I remember this being discussed in regards to renal failure?



    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


  • edited May 2016
    Don, Katy and Robert,

    Thank you for your input.
    My thought was to develop a well-researched definition, review it with that Physician specialty group for final determination, and, of course, leave a disclaimer for MD clinical judgment and interpretation. It would then be signed off by the CMO, Legal and other interested parties. Our Physicians are employees of the hospital so that makes this approach a little more feasible. I have also spoken with a couple of Directors of service and they agreed with this approach as long as they did not have to create the definition. :)

    The problem we have (and I HATE to say this), is that some MDs are not clear on what some queried diagnoses actually are. I have even had Surgeons ask "what is CKD?" (maybe it was just the abbreviation) and for clarity on other DXs as well.
    The other issue I was hoping to help was Insurance denial. The definition of Acute Respiratory Failure claimed by the MD for the Insurance CO. was not what we use based on our CDI Pocket Guide and other resources I have found.
    I wanted to make it a hospital policy--if this is even possible.
    Katy, can they still disagree with a standard definition even if it is hospital policy? And if that is the case, maybe it is not worth all the effort I would need to put forth. Maybe, I should just go with MD to MD dialogue as you suggested, Robert. Then again, I will also review what Dr. Trey La Charite discussed in pre-conference session for Physician Advisors as Don suggested. Apparently he claims they do add some defense for denials.

    Thanks so much for your help! I love you CDI Talk!!
    -Jane

  • Jane,
    I think your plan sounds good from an educational perspective in that having a prescribed definition can guide further education to the MD's. you could bring these definitions to department meetings, place them on queries, use them in conversations with MD's, etc.
    What I am unsure about is whether this will have any impact on your ultimate goal of reducing denials. When I say unsure, I am literally "unsure". I would be interested in other opinions on this as I am not intimately involved in the RAC process at my facility. I feel like there have been times where RACs have denied cases even when the dx seems to fall into a fairly well-known definition, but I could be wrong. Specifically, I believe I heard this discussion surrounding Renal Failure. I think this surrounds which criteria is being used in defense of the dx (RIFLE, KDIGO, AKIN, etc). If the ultimate goal is to reduce denials, it may be worthwhile to research what kind of criteria is being referenced by the RACs.

    Good luck!


    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


  • edited May 2016
    Me, I'm just glad I'm RAC exempt. I do agree with a standard definition and that it should be a recognized definition supported by literature. Such as the KDIGO standards for renal failure (acute and chronic). If your providers all support the definition, then they should be able to defend it if a denial occurs. When our query forms were developed we had providers in the specialties review them to ensure that the definitions were correct and include references in some cases to the standard being referenced. It doesn't really matter what definition an insurance company or RAC auditor uses as long as your providers can defend their diagnosis. Physician judgment is critical and is recognized by CMS and very few physicians are willing to contradict a peer. I also agree with Don's suggestion that you get a physician advisor to advocate as well.

    Good luck to you :)

    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
     
    “Patriotism is easy to understand in America; it means looking out for yourself by looking out for your country" Calvin Coolidge

  • One point about Jane's comment on reviewing the pre-conference materials
    -- those materials are not available on the ACDIS website (in case
    anyone goes looking).

    Don

  • edited May 2016
    Jane - I would be a little careful of pushing the doctors with a "hospital policy". Compliant coding is based on the documentation and honoring the physicians' clinical judgment, not based on a policy. Just my thoughts... Linnea

  • I believe that advocating and using current evidence-based definitions for disease processes in order to define and document key conditions is a good strategy. It is important, or course, to cite your source, ensure the medical staff and subject-matter experts accept any definition, and also make sure Compliance is onboard with any definitions. We have built definitions into many of our query forms, but since we had assistance from a consulting firm, I can't make all public as they are proprietary.

    I can attach a few 'fact sheets' we have published independently.

    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002
    Fax:  415.600.1325
    Ofc:  415.600.3739
    evanspx@sutterhealth.org

  • Katy: We have had denials for acute renal injury citing and using the KDIGO definitions. I continue to advocate adoption of this definition, and I believe the RACs 'denial' is unfounded given:
    1. The condition is clearly stated in the record
    2. The condition meets a universally-accepted definition.

    Best - Paul

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

    Manager, Regional Clinical Documentation & Coding Integrity
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    evanspx@sutterhealth.org


  • Yes Paul, This is exactly my point. I thing definitions are helpful. Our physicians often ask for them. Especially when it comes to dx like: malnutrition, encephalopathy, Renal failure and resp failure. I think providing the information is helpful and I can see having organization-wide policies could be a good reference for MD's and CDI staff. I am just unsure that this really protects from denials. You could choose to define a dx whatever way you want, but it seems like RAC will still deny if they do not agree with the definition (or sometimes for an unknown reason?).

    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


  • Katy: I am not sure a 100% protection from a RAC denial is feasible - however, I do believe adoption of 'reasonable' definitions is one vital step to ensure correct and quality data is reported, and can consequently be defended. Personally, I have seen cases whereby I feel the RAC has 'gone overboard'. I believe we all have to be ready to take our cases to an Administrative Law Judge, when needed. I believe it is important that we accept the RAC finding, when we feel it is valid, but also that we reply vigorously when we feel the denial may be w/o foundation.

    I find myself frustrated that the RAC will state something such as 584.9 (ARF) does not meet their definition of the condition, and yet I can cite literature supporting the definition we have documented and coded. The RAC does not cite what they believe to be a valid definition for various conditions, and this makes the situation even more murky.

    Best to all in this endeavor -

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

    Manager, Regional Clinical Documentation & Coding Integrity
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    evanspx@sutterhealth.org

  • edited May 2016
    Paul,

    Have you had any success with RAC, defending your argument that the physician documented AKI or Acute Renal Failure in the record therefore is reportable? We have had two denials stating that ARF did not meet RIFLE criteria therefore was unreportable but ARF clearly documented by the physician. Suggestions on successful verbiage for RAC denials in which physician has clearly stated diagnosis?

    Thanks,

    Dorie Douthit, RHIT,CCS
    ddouthit@stmarysathens.org

  • Yes. Very frustrating! It seems pretty ridiculous that they cannot just state a definition (or set of criteria) that DOES meet their definition. Especially with something like renal failure which is often diagnosed/staged by using lab values!

    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


  • Dorie: Yes - see below: Identifying Information DELETED


    We are in receipt of your letter regarding the case above. We contest your decision to delete acute renal failure from this case. There are several progress notes clearly stating the patient was admitted with acute renal failure and the patient presented with a serum creatinine of 1.9 which was aggressively treated with intravenous infusion of fluids. The creatinine improved to 1.0 as the acute renal failure was treated with hydration. This is very common for ‘prerenal azotemia’ as this is ARF due to dehydration. As the condition IS stated within the body of the record, meets clinical criteria for the diagnosis, and was aggressively treated, it clearly should be coded.

    In keeping with the Guidelines published in Coding Clinic, the diagnosis of acute renal failure is clearly stated by a physician actively involved in the care of this patient and authorized to establish a diagnosis.

    We acknowledge this condition is not explicitly mentioned in the summary, but when a condition is clearly documented within the body of the record and meets the UHDDS definition of a reportable condition, it is to be coded. It is not uncommon for the summary to neglect to list many important and specific diagnoses that are clearly stated within the body of the record, but which clearly exists and it is an error not to code these conditions in certain situations. This is not what you term a ‘conflict’ between the attending physician and the physician treating the acute renal failure. The attending used a generic and non-specific term, but the body of the record clearly documents the more precise and accurate diagnosis – acute renal failure.





    References:
    AHA Coding Clinicâ for ICD-9-CM, 2Q 2000, Volume 17, Number 2, Page 15
    Question:
    A diagnosis of COPD on an anesthesia evaluation is signed by the anesthesiologist. No other medical record documentation exists stating COPD for this patient. Should COPD be reflected by the attending physician in the body of the record such as the history and physical to be codable?
    Answer:
    It would be appropriate to assign code 496, Chronic airway obstruction, not elsewhere classified, for the COPD. Coding is based on physician documentation. The anesthesiologist is a physician. However, if there is conflicting information in the record, query the attending physician for clarification. Refer to Coding Clinic Second Quarter 1992, pages 16-17 for a previous example of COPD documented in the history section of the medical record. If there is evidence of a diagnosis within the medical record, and the coder is uncertain whether it is a valid diagnosis, it is the coder's responsibility to query the physician to determine if this diagnosis should be included in the final diagnostic statement. Evidence of documentation is not limited to the face sheet, discharge summary, or history and physical.
    The patient clearly meets this clinically current definition of acute renal failure.

    “An abrupt (within 48 hours) reduction in kidney function currently defined as an absolute increase in serum creatinine of more than or equal to 0.3 mg/dl (≥ 26.4 μmol/l)”

    Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury
    Ravindra L Mehta1, John A Kellum2, Sudhir V Shah3, Bruce A Molitoris4, Claudio Ronco5, David G Warnock6, Adeera Levin7 and the Acute Kidney Injury Network
    Available online http://ccforum.com/content/11/2/R31

    We do not agree with your finding and wait to hear from you.

    Sincerely,

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

    Manager, Regional Clinical Documentation & Coding Integrity
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    evanspx@sutterhealth.org


  • edited May 2016
    Paul,
    You bring up a very valid point; the RACs are not stating values backed by literature.
    I believe if we have to provide back up, so should they.
    Different laws for different folk.......

    Francisca Wojciechowski, BS, RHIA, RHIT, CCDS


  • Francisca – Absolutely, it seems very ‘subjective’ at times and even like a double standard when the RAC does not cite criteria.

    Personally, we really love to research, cite and use evidence-based criteria because it keeps us current with pathophysiology and helps me review charts more consistently. All members of our team take time to read and research criteria, and we are a part of the team that devises these criteria endorsed by our medical staff.

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

    Manager, Regional Clinical Documentation & Coding Integrity
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    evanspx@sutterhealth.org

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