New ACDIS-AHIMA query brief

bmurphy@hcpro.combmurphy@hcpro.com
in CDI Talk Archive
Hi CDI Talkers,

I wanted to let you know that the new joint ACDIS-AHIMA query practice brief is now out. It will be published in the Feb. Journal of AHIMA, and we will be publishing it on the ACDIS web site. Here is a direct link to an online version:

http://www.tinyurl.com/AHIMA2013Querybrief

I'm proud that ACDIS collaborated on this practice brief and played a significant role in shaping the content, and I hope that it enables you to do your jobs more effectively. There are some fairly substantial changes, particularly to yes/no queries, and some previous statements have been refined/clarified. Your comments and discussion are appreciated.

Take care,
Brian

Comments

  • leah.taylorleah.taylor
    edited May 2016
    THANKS Brian!!!!!

    Leah Taylor, RN, CCDS
    Data Integrity Specialist/RAC Coordinator
    Iredell Health System
    557 Brookdale Drive
    Statesville, NC 28687
    704-878-7436 office
    704-878-4624 fax
    leah.taylor@iredellmemorial.org


  • epraczepracz
    edited May 2016
    Brian,

    Thank you so much for sending.

    Eileen Pracz, RN CCDS
    Certified Clinical Documentation Specialist
    Oregon Health & Science University
    Phone 503-418-4023
    Fax 503-494-8206
    pracze@ohsu.edu




  • vanessa.falkoffvanessa.falkoff
    edited May 2016
    Very interesting... Thank you Brian!



    Vanessa Falkoff RN

    Clinical Documentation Coordinator

    University Medical Center

    Las Vegas, NV

    vanessa.falkoff@umcsn.com

    office 702-383-7322

    cell 702-204-0054


  • tanujabhattessatanujabhattessa
    edited May 2016
    Thank you so much Brian!!

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Awesome! Thanks!

    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
    Compelling and interesting for several reasons - in particular, the Brief states that "yes/no" queries 'can be compliant' in special situations, and also states one may pose a query using language such as "do you agree".


    In addition to present on admission (POA) determinations, yes/no queries may be utilized under the following circumstances:

    * Substantiating or further specifying a diagnosis that is already present in the health record (i.e., findings in pathology, radiology, and other diagnostic reports) with interpretation by a physician
    * Establishing a cause and effect relationship between documented conditions such as manifestation/etiology, complications, and conditions/diagnostic findings (i.e., hypertension and congestive heart failure, diabetes mellitus and chronic kidney disease)
    * Resolving conflicting documentation from multiple practitioners

    See Query Examples for Query Example: Yes/No Format



    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

  • sharon.colesharon.cole
    edited May 2016
    I love, love, love the new practice brief! Absolutely awesome job done by the committee!! Some really wonderful examples of leading and nonleading - so much more helpful! The yes/no queries kind of scare me, but I do want to use the new brief as an excuse for making our queries a permanent part of the medical record. So many of our docs will write on the query but not include the diagnosis in their progress notes/DC summary, so then it doesn't get coded. For example: acute diastolic HF will get written on the query, but the notes still only say: "hx CHF. volume overload, BNP3568 this am, LV hypertrophy, add Bumex gtt. And then later CHF resolved. So all that's coded is 428.0.

    ***I do have a question regarding the brief though: The example of a multiple choice query on page 6 regarding CHF says "A recent Echo..." I was under the impression you could not introduce old records into the current admission. So does this mean the echo was done during the current admission or can we use echo's from previous hospitalizations? We have a hybrid record so previous labs/xrays/tests are all there when reviewing the current admit.

    Thanks for all the wonderful advice, assistance, support, everyone gives!

    Sharon Cole, RN, CCDS
    CDI Specialist Team Leader
    Providence Health Center
    254.751.4256
    Sharon.cole@phn-waco.org

  • angelisa.romanelloangelisa.romanello
    edited May 2016
    Awesome. Thank you Brian

    Lisa Romanello,RN,BSN,FNS,CCDS
    Clinical Documenatation Improvement Specialist
    CJW Medical Center
    Chippenham Campus
    804-228-6527



  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I love this. We have already been doing this on our rad/path query!

    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

  • paflor2paflor2
    edited May 2016
    In reading over the Practice Brief, can anyone explain what an "escalation policy" is regarding Non-Compliant Example 3 ("escalation policy" is recommended under the rationale) about CAUTI? Have I overlooked the definition of "escalation policy" earlier in the document?

    Thanks for any assistance

    Pam Florence, RN
    Clinical Documentation Specialist
    UK HealthCare
    Phone: (859) 323-1236
    Pager: (859) 330-8608
    E-mail: paflor2@uky.edu





Sign In or Register to comment.