New CDI Query Brief

fantinsfantins
in CDI Talk Archive
Hi Brian,

Could you please provide an example query of a multiple choice question where there is only one reasonable option where it is not introducing new information.


Thank you,Susan

Comments

  • epraczepracz
    edited May 2016
    I would like that too.

    Thank you,
    Eileen

  • bmurphy@hcpro.combmurphy@hcpro.com
    edited May 2016
    Hi Susan, sorry for the late reply on this... can you provide a brief scenario in which there is only one reasonable option?

  • fantinsfantins
    Sure.

    How about CHF Patient:

    88yo with SOB RR 20, HX of CHF, swelling in lower extremities, recent
    weight gain, EF 33%, on po lasix at home, sleeping with extra pillows
    present to ER. BNP 5000, treated with O2, Bolus of IV lasix and Lasix
    gtt, CXR + pl effusion and physician documents CHF exacerbation.

    Query to clarify CHF exacerbation - only choice should be Acute Systolic
    Heart Failure based on above.

    Is this an example of what the article is referring to??

    Thanks,
    Susan Fantin, RN, BSN, MSA, CCDS, CDIP
    Senior Director, Clinical Documentation Improvement Specialist,
    Performance Technologies
    The Advisory Board Company
    202-266-5862 direct | 248-321-0256 mobile | 202-266-5700 fax
    fantins@advisory.com | www.advisory.com
    Stay in the know
  • fantinsfantins
    edited May 2016
    Included choice would also be other and unable to determine

    ~Susan



  • ddouthitddouthit
    edited May 2016
    Susan,

    The example below does not specify systolic dysfunction or failure so I'm thinking would be able to do something like the following (since this is an exacerbation it will be an acute on chronic chf).


    If known, please document the type of the patient's acute on chronic Congestive Heart Failure:
    Diastolic
    Systolic
    Diastolic and Systolic
    Other more appropriate diagnosis
    Unable to determine


    Dorie Douthit, RHIT,CCS
    ddouthit@stmarysathens.org


  • sharon.colesharon.cole
    edited May 2016
    Or maybe CT brain showing mass effect, midline shift"?

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


  • fantinsfantins
    Thanks Dorie.

    I am trying to get at the new query brief. Would like an example
    (according to the brief) when there is only ONE OPTION - see page 2 of the
    article second paragraph:

    "Multiple choice query formats should include clinically significant and
    reasonable options are supported by clinical indicators in the health
    record, RECOGNIZING THAT THERE MAY BE ONLY ONE REASONABLE OPTION"

    Looking for guidance here from ACDIS/AHIMA.

    Susan Fantin, RN, BSN, MSA, CCDS, CDIP
    Senior Director, Clinical Documentation Improvement Specialist,
    Performance Technologies
    The Advisory Board Company
    202-266-5862 direct | 248-321-0256 mobile | 202-266-5700 fax
    fantins@advisory.com | www.advisory.com
    Stay in the know
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    In this case, mass effect or a radiological finding, couldn't you use the agree/disagree type query. If I remember correctly, this is referenced in the query brief as being ok now?

    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

  • sharon.colesharon.cole
    edited May 2016
    We're going to have to update query forms!

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


  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    For example...

    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


  • ddouthitddouthit
    edited May 2016
    Thoughts on how to word such query? I don't think Midline shift nor mass effect have a code in ICD9. I remember there was an article a while back in newsletter/journal that spoke to radiology findings on Brain MRIs/CTs?

    Dorie


  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    Nicely done, Katy

    Paul Evans, RHIA, CCS, CCS-P, CCDS
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    We use this query form

    Paul Evans, RHIA, CCS, CCS-P, CCDS
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    They don't. we use this.

    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



  • bmurphy@hcpro.combmurphy@hcpro.com
    edited May 2016
    Hi Susan, here is one example submitted by a member of the committee that helped put the brief together:

    The history and physical states a diagnosis of acute anemia and the patient was transfused with two units of blood due to a decreased H&H secondary to an acute bleeding gastric ulcer. Can you please specify the type of anemia associated with the decreased H&H and treated with the two units of blood?

    Acute blood loss anemia
    Unable to determine
    Other: _________________


  • ddouthitddouthit
    edited May 2016
    Awesome!! Thanks Katy.

    Dorie


  • lsipos@monument.healthlsipos@monument.health
    edited May 2016
    Dorie
    How about including the CT findings, medications, (decadron/mannitol?), any clinical indicators or neuro findings.
    Are you referencing brain herniation and cerebral edema? Just brain herniation? Midline shift? Cerebral edema? Other? Unable to determine?



  • fantinsfantins
    Thanks!

    Susan Fantin, RN, BSN, MSA, CCDS, CDIP
    Senior Director, Clinical Documentation Improvement Specialist,
    Performance Technologies
    The Advisory Board Company
    202-266-5862 direct | 248-321-0256 mobile | 202-266-5700 fax
    fantins@advisory.com | www.advisory.com
    Stay in the know
  • fantinsfantins
    Katy and Paul - great example. Would there be a time when only the 1
    option was not related to a radiology, lab, etc
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I like that!

    Katy Good
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Susan: We only use the form to confirm a diagnosis that is stated by the Radiologist - we also check the record prior to using the form to ensure the condition is reportable per the UHDDS Guidelines. We specifically created this form for patients with Neoplasms and ICH because the term 'midline shift' is used often in our community. Yet, we also note the patients have abnormal neurological exams and are placed on Decadron or Mannitol and the sodium goal is around 145. Often a radiologist will dictated a hernia or significant edema of the brain.



    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

  • fantinsfantins
    edited May 2016
    Thank you Paul for that additional information. - Susan




  • sharon.colesharon.cole
    edited May 2016
    Yes me too, thanks everyone! Don't know how I would do this job sometimes without all the networking that goes on here on CDI Talk!!

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


  • Unknown
    edited May 2016
    Thanks so much! You guys rock!
    Jamie Dugan
    Baptist Health System
    Jacksonville, Florida

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