Query for Diagnosis with no clinical evidence

Unknown

Does anyone have any examples of queries (or ideas on how to resolve) when a provider documents a diagnosis when there is no clinical data that supports it?
Specifically we are having problems with documentation of acute respiratory failure, severe protein calorie malnutrition, and acute kidney injury. The doctors are consistently documenting these throughout the chart but there is no clinical data to support it. Sometimes the coders will code it because "it's written" and other times they want us to clarify. How do I get a doctor to "unwrite" their diagnosis because it truly doesn't exist and should not be coded.

robert.hodges2

That can be a challenge. I have provided guidelines for acute renal failure etc based on articles and other references that I then discuss with the provider. It usually doesn't work well as a written query from my perspective because if that is what they believe then that is what they are going to do and I'm not in a position to contradict them. I just try to have a discussion and see what happens from there after we have that opportunity to talk. Usually I ask something like, "you're documenting this but I can't find any results that go along with that diagnosis. Can you tell me how you came to that decision?"

It is a big grey area.

Robert

Robert S. Hodges, BSN, MSN, RN
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
 
"Anyone who has never made a mistake has never tried anything new." -Albert Einstein 

dallend@einstein.edu

We do not query when an MD documented an invalid diagnosis. That really should be handled Doctor to Doctor. I would bring it to the attention of your manager. Depending on your facility - perhaps the physician who supports quality or UM can help. Our director has brought this type of issue to the attention of our Chairs of medicine and surgery.
I hope this helps.

Unknown

I usually ask for further documentation of a clinical picture and criteria to support the diagnosis. Sometimes I get a response and sometimes not. I agree face-to-face discussion is better. It worries me that these diagnosis are in the chart and a potential for when RAC audits. Perhaps that's an unfounded worry because the physician documented it.
Thanks for your input it was helpful.

Unknown

Is the RAC going to dispute the physician on his written diagnosis? Example, the physician states the patient has suspected pneumonia. He writes this in his H&P and on the discharge summary. The x-rays are all negative for pneumonia but does states the patient has infiltrates. In the physicians mind the patient does have pneumonia and is treated as such. Who makes the call here?





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robert.hodges2

Physicians call based on the clinical picture. A patient can have pneumonia with a negative chest x-ray.

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602

dog

I have queried to have diagnoses removed from the chart for lack of clinical evidence. Basically what I do is cite standards for the diagnosis and ask the physician either to provide clinical support for the stated diagnosis or consider removing the diagnosis. If the physician still wants to stick to his/her guns, then our position is that they get to defend the diagnosis if challenged by an outsider, but at least we have it on record that we brought our concerns to their attention.

Renee

Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital

sbeatty

I agree with Robert. The attending MD determines the PDx based on Assessment and ROS, not the radiologist who doesn't see the patient. As long as the MD restates the possible/probable qualifier to his PDx in the discharge summary, we would go with the pneumonia.


Sandy Beatty, RN, BSN, C-CDI
Clinical Documentation Specialist
Columbus Regional Hospital
Columbus, IN
(812) 376-5652
sbeatty@crh.org

"Obstacles are those frightful things you see when you take your eyes off the goal." Hannah More

-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, May 20, 2010 4:28 PM
To: Beatty, Sandra L.
Subject: RE: [cdi_talk] Query for Diagnosis with no clinical evidence

Physicians call based on the clinical picture. A patient can have pneumonia with a negative chest x-ray.

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602

dawn.laroque

We do no query Physicians for the "reliability" of a diagnosis, if the clinical picture does not support the diagnosis. This is left for Physician to Physician discussions. Below is an excerpt from AHIMA's article "Managing an Effective Query Process". I would say that if you are going to query to question the validity of a diagnosis, make sure you are covered by policy.


"When Not to Query
Codes assigned to clinical data should be clearly and consistently supported by provider documentation. Providers often make clinical diagnoses that may not appear to be consistent with test results. For example, the provider may make a clinical determination that the patient has pneumonia when the results of the chest x-ray may be negative. Queries should not be used to question a provider’s clinical judgment, but rather to clarify documentation when it fails to meet any of the five criteria listed above—legibility, completeness, clarity, consistency, or precision.

A query may not be appropriate simply because the clinical information or clinical picture does not appear to support the documentation of a condition or procedure (e.g., documentation of acute respiratory failure in a patient whose laboratory findings do not appear to support this diagnosis). In situations where the provider’s documented diagnosis does not appear to be supported by clinical findings, a healthcare entity’s policies can provide guidance on a process for addressing the issue without querying the attending physician."

Dawn LaRoque Rn, BSN, CCDS
Supervisor, Documentation Program
Riverside Regional Medical Center
dawn.laroque@rivhs.com
757-594-2063

Unknown

That's how I feel....at least it would be on record that we brought up
the concern. Thanks.

Gina Spatafore, RN
Clinical Documentation Integrity Specialist
Waterbury Hospital
203 573 7647

Unknown

It's not the diagnosis of PNA that I'm worried about...it's things like acute respiratory failure, acute kidney injury and severe protein calorie malnutrition. I don't know if RAC will be looking for specific clinical data to back up what is written but I worry....

Gina Spatafore, RN
Clinical Documentation Integrity Specialist
203 573 7647

robert.hodges2

I still feel it's the provider's professional call, as long as they are willing to defend their decision to an outside auditor. But as others have said who are fortunate enough to have a physician advisor, you could have them review the case and then have a provider to provider discussion. That may be a way to document your concern (referred to physician advisor) without having to confront the provider directly on the diagnosis.

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602

Unknown

I was just using pneumonia as an example...




Malinda

Unknown

yes they will look for the clinical data to support the diagnosis. Also if
there is a query written they will look for the data to be included in the
query( if they have the query for their review).



Kim Beard
Clinical Documentation Specialist

cstukenberg

I have not had experience with RAC taking back because of a diagnosis that is NOT supported by diagnostics; however, we are just in the early stages of RAC sending requests, so it may be coming. However, keep in mind medical necessity is coming. In addition, we did have the QIO come back and say pneumonia was not justified because there was not a supporting positive x-ray for it. We even had a physician-to-physician conference call to discuss how the patient may have the clinical picture of pneumonia without a positive chest x-ray. The QIO physician would not agree to this and denied our pneumonia diagnosis. This was very frustrating because it allowed no room for clinical judgment by the physician taking care of the patient. I have a concern with this because we try to have the physicians document the true clinical picture of the patient, but when they do, they are "dinged" if there is not the supporting diagnostics. We are "caught between and rock and a hard place" so the saying goes. I guess your physician will need to be able to present a good strong case for whatever he/she documents. Just food for thought.

Colleen Stukenberg MSN, RN, CMSRN, CCDS
815-599-6820

Unknown

In regards to querying the provider, how far post discharge can you query? Is there an industry standard, for example 6 month after the claim has been dropped?

Malinda

dog

It's not just the RACs; it's also, as others have said, the QIO and the managed care auditors who demand clinical evidence and have sent denials for lack of clinical support. I don't feel I'm trying to challenge the physician, but sometimes they use terminology that does not fit the guidelines. I don't think it's different than asking a doctor who has written AKI to consider ARF. We feel we'd rather police ourselves than have an outsider do it.

As for this which was quoted above, "In situations where the provider’s documented diagnosis does not appear to be supported by clinical findings, a healthcare entity’s policies can provide guidance on a process for addressing the issue without querying the attending physician," I'm the process. I have a physician advisor, but we feel he is here to support me, not to twist arms. Plus his specialty is outside the scope of most of our patients; it would be awkward for a gastroenterologist to challenge a cardiologist regarding an NSTEMI, for instance.

I have mentioned in previous posts that I had to educate a physician not to write vent-dependent resp failure inappropriately; showing him research articles that I found, rather than constant queries that went nowhere, did the trick. When he occasionally slips up, I will gently remind him and he fixes it. Generally the physicians have not been resentful of these questions from a mere nurse; if they need re-educating on the documentation standards, that's the time to provide it. Sometimes they remove the diagnosis, but other times they explain their justification for the diagnosis and that is great, too. Educational for me as well.

My goal is to have my chart go to the coders as clinically accurate as possible. I do that by treating the physicians with respect but not awe.

Renee

Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital

dbutler

Renee -- I LIKE that, "treating with respect, but not awe"

In response to many other's comments:
From networking conversations, I understand that RAC is taking back AKI
/ARF when not clinically supported by the lab data values -- I
understand that the RIFLE criteria have been cited.
Our general approach is to code the diagnosis when consistently
documented by the attending, but we do so with concerns about a RAC
audit. We do seek to provide concurrent education on the RIFLE
criteria.

Personally, I feel that pneumonia is different and should be much more
defendable than a dx for ARF/AKI with a Cr shift of perhaps 35%.

We do not have a physician advisor at this time (are recruiting for a
Medical Director that would be 50/50 UM/CDI).

pfowler

I have a question. Anemia is diagnosed a lot! The MDs will use anemia of chronic disease or Anemia secondary to GI bleed.. I tell them that is the source of the bleed but I need the type of anemia and anemia of chronic disease I need the disease clarified. Am I being too picky or this what I should be querying?

Patsy Fowler RN, MSN, CCDS
Certified Clinical Documentation Specialist
Marion Regional Medical Center
PO Box 1150
Marion, SC 29571
Office 843-431-2044
Cell 843-431-2863
Fax 843-431-2475

robert.hodges2

I query for the same thing all the time. Sometimes they will respond and sometimes not. Depends on the circumstances. GI bleed is easy because I can ask if there is a link between the GI bleed and the anemia and if so if the blood loss is acute or chronic. Anemia of chronic disease is usually a lot more challenging, but sometimes I will get a more specific diagnosis. Communication with the provider is key for me and presenting what you see. The challenge here is not to be leading.

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602

dallend@einstein.edu

I'm not sure if there is an industry standard. I think you need to be careful how far post discharge you query. The furthest out we have queried has been 2 months - usually as a result of our no cc/mcc report we receive when we get our CMI numbers.

dallend@einstein.edu

Great comment.
I think the handling of this does depend on your facility and the physicians. We do not have a physician advisor - our Medicine and Surgical Dept Chairs handle these issues. They may bring in the head of dept to assist. It was decided at the time our program was put in place that we would not query regarding inappropriate diagnoses and that decision still stands.
I think it's great if your physicians are receptive to these discussions with CDS.

dallend@einstein.edu

Anemia is one of our most common queries. We do not usually query to further clarify anemia of chronic disease - the clarification does not usually impact soi/rom/DRG. It depends on the individual chart though. Acute blood loss anemia, post op anemia, chronic blood loss anemia - we will pursue.
If we see that a pt was transfused we will leave a query.

Unknown

It does count as an SOI/ROM in acute renal failure cases when they received a blood transfusion.

dallend@einstein.edu

I think it depends on the case and the other comorbidities. We have times when even acute blood loss anemia has not impact on SOI/ROM - it amazes me. We usually check in our encoder to see if there is an impact.

Unknown

You're right....we could never memorize the SOI/ROM's because each case is different and takes different things into account.....the age, where they were discharged to, etc. I forgot to mention that anemia due to CKD is the one that impacts with SOI/ROM.