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.
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 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
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
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
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
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
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
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
-- those materials are not available on the ACDIS website (in case
anyone goes looking).
Don
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
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
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
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
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
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
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
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
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