possible, probable, suspected???

arsusott@msn.com

I was just needing a little help on constructing a compliant query. We were taught in our organization (by a consultant when we started our cdi program) that when we wrote a query we could write... pt with elevated wbc, positive blood cultures, hypotensive, hypoxemia, started on Zosyn are you possibly/probably treating patient for sepsis or other dx. However; we had a DRG audit recently in our coding department and were told that we can't use words like possibly/probably in our query unless those words were already documented in the medical record. Does anyone have any thoughts on this? Can we introduce words like possibly/probably? I have read the 3 Q 2005 CC regarding the coding of possible dx but I can't find any guidelines on using those words in a query. Any guidance/policy would be greatly appreciated.

Thanks,
Angela Susott, CCS, CCDS
Missoula, MT

Unknown

I believe that unless the words possible or probable are written by the physician you should not use them. It would be a "leading query". AHIMA has an 8 page document on "Managing an Effective Query Process". There are also many books written on this topic. Actually there are no regulatory, mandatory rules surround the query process. However AHIMA's guidelines and other recognized organizations guidelines are generally accepted by Medicare and other auditing agencies as the "gold standard".

I will quote two selections from AHIMA: " It is recommended that queries be written with precise language, identifying clinical indications from the health records and asking the provider to make a clinical interpretation of these facts based on his or her professional judgment of the case. Queries that appear to lead the provider to document a particular response could result in allegation of inappropriate upcoding. The query format should not sound presumptive, directing, prodding, probing, or as though the provider is being led to make an assumption."
Also, "Ask is the query necessary, was the language used in the query not leading or otherwise inappropriate, make sure the query did not introduce new information from the health record."

http://library.ahima,org/xpedio/groups/public/documents/ahima/bok1_040494.hcsp?dDoc...

Cindy Fessler RN, BSN, CDS
Portland, Oregon

blefevre

Hi Angela,
I think that the reason the query is not compliant is that we can not
introduce a word into the query that is not already on the chart. The
query would be compliant if the symptoms were displayed and then the
open ended question of "could you provide a diagnosis for the above
symptoms". If you query by saying "could the patient have a probable or
possible sepsis", the word sepsis is being introduced before it was
written in the chart. We find it better to have preprinted query sheets
with definitions of various diagnosis and in our queries, we ask the
physician if the patient has any of the above diagnosis, with an "other"
option. I wonder if the audit issue is the diagnosis word, and not the
possible/ probable piece to it.
Hope this helps!
Barbara Lefevre RN BSN
Clinical Documentation Specialist
Saint Mary's Hospital
Waterbury, Connecticut

ctrygar

There is an example of an appropriate query in the AHIMA guidelines for querying that Supplies all the clinical documentation similar to what you list then it states are you treating any of the following:
Ac resp failure, chronic resp failur, hypoxemia, or other. I do not see why you couldnt list your clinical findings in the chart EX temp, wbc, antibiotics etc. and then state: are you treating any of the following: bacteremia, sirs, sepsis, other. would this be an exceptable query?

cheri

Unknown

As long as you are not leading the physician I don't see why you could not list the different dx and have the provider check what is appropriate. If the physician states other a explanation of what other means needs to be supplied.




Malinda

janrumdavis

When our consultants were here training us they developed a sepsis query form. The form states the medical record reflects the folowing findings suggestive of sepsis: then there are 3 columns. Column for clinical indicators, another to check if indicator present, and another to write the location in medical record which reflect the clinical findings. The clinical indicators listed are: fever or hypothermia, tachypnea, tachycardia, oliguria, hypotension, metabolic acidosi, acute onset of confusion associated with disease process/AMS, shock, and positive blood cultures. Below the columns there is a statement asking the physican to "please clarify and document in the progress notes whether based on your medical judgment of the clinical indicators outlined above, are you treating this patient for a known or suspected generalized sepsis vs. some other condition?"

tiffany_susan

This is an example of a query I use:

The medical record reflects the following clinical findings, treatment,
and risk factors.
Pn4/20,4/21,4/22: Pt has acute renal failure noted by resident
Creatine 1.2(previous creatine in EPIC of 0.9-1.3), IV fluids at KVO, no
change in electrolytes.

Please clarify and document your clinical opinion in the progress notes
and discharge summary the definitive and/or presumptive diagnosis,
(suspected or probable), related to the above clinical findings. Please
include clinical findings supporting your diagnosis.

renal insufficiency

OTHER explanation of clinical findings

Unable to determine (no explanation for clinical findings)

Thank You,
Susan Tiffany RN, CCDS
Supervisor Clinical Documentation Program
Guthrie Healthcare System

"Twenty years from now you will be more disappointed by the things you
didn't do than by the ones you did do. So throw off the bowlines. Sail
away from safe harbor.Catch the trade winds in your sails. Explore. Dream.
Discover." Mark Twain

pfowler

Do you always query for clarification/definitive dx if the physician
documents renal insufficiency?



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

Unknown

I do - I list the lab values and ask if they can clarify the terminology 'renal insufficiency'.
Options may include acute renal insufficiency, CKD with stage, acute renal failure etc.

Charlene

twoods

I CLARIFY ALSO. TYTW

blefevre

It depends if the bun and creatinine fit the definition of acute renal
failure or ckd with staging. If it does, then yes, I would query.



Barbara Lefevre RN BSN

Clinical Documentation Specialist

Saint Mary's Hospital

Waterbury, Connecticut

twoods

Does your Medical Staff define ckd vs insuff? Or do you use Harrison's Medical or other resource?

Theresa Woods, RN, MSN
Jennings American Legion Hospital
1634 Elton Road
Jennings, La 70546
Phone: 337-616-7297
Fax: 337-616-7096
twoods@jalh.com

robert.hodges2

As do I. I always ask for a more specific diagnosis even if it doesn't
change the DRG. I'm trying to get them in the habit of doing it.



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

pfowler

That is what I do. I am glad you said that. I try to get them to show
severity of illness and that does not always change the DRG, but does
provide better documentation practice.



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

sbeatty

So do I. The process should be about a quality medical record to
communicate the patient's true severity of illness. If you focus on DRG
change, you are foremost.maximizing reimbursement



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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

lspryszak

Since the diagnosis must be documented as possible/probably/suspected/(other term) at the time of DISCHARGE (note emphasis), then personally, I wouldn't encourage using these terms in a query since it may be documented when your query is answered but then not mentioned at discharge, thus invalidating coding of the condition.

The support for this rule is in the Official Coding Guidelines:

ICD-9-CM Official Guidelines for Coding and Reporting
Effective October 1, 2009
Narrative changes appear in bold text
Items underlined have been moved within the guidelines since October 1, 2008

Page 92: H. Uncertain Diagnosis
If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals."

I would be especially careful about using the uncertain terminology in queries that address target diagnoses: pneumonia, sepsis, renal failure, etc., since an audit might well invalidate the condition if it's only documented once or twice, even if the treatment plan appears to support the diagnosis.