Need to "Confirm" Diagnoses Clearly Documented
Evolving Medical Definitions and the Impact upon CDS Professionals,
Coding Professionals & Compliance
Medicine and disease evolve quickly. For instance, I recall my senior
year in college when the physician teaching one of our Pathophysiology
Classes gave me the following assignment: “Define acute renal failure
(ARF), based on signs, symptoms, lab findings – be sure to cite
abnormal laboratory values”. I recall his exact words because of the
subsequent undertaking I was compelled to take in order to ‘define
ARF’.
Bear in mind this the year was 1989 – the tools of the Internet were
not available. Initially, I thought the assignment would be ‘not too
difficult’. I was incorrect. I went to the Medical Library, and I
must have found at least a dozen different ‘laboratory-defining’
definitions for ARF – all involving different levels of Serum BUN,
Creatinine and Potassium, and most with the key value pertaining to
Creatinine. Eventually, and after a lot of research and frustration,
I settled on a definition that included, among other key findings, those
below:
● Sudden rise in serum creatinine of >1mg/dl/day
● Rapid BUN elevation (greater than 20 mg/dl)
(I recall my professor accepted this definition, but I believe
he assigned this task to me for a reason – he wanted me to comprehend
the individual complexity and variation involved when one undertakes to
establish a ‘universal definition’ for a disease process).
We know now the definition I provided some time ago is outdated.
Consider the 2012 KDIGO Clinical Practice Guideline for Acute Kidney
Injury Definition (AKI means ‘acute kidney injury):
AKI is defined as any of the following (Not Graded):
● Increase in SCr by X0.3 mg/dl (X26.5 lmol/l) within 48 hours;
or
● Increase in SCr toX1.5 times baseline, which is known or
presumed to have occurred within the prior 7 days; or
● Urine volume o0.5 ml/kg/h for 6 hours.
Reference: http://www.kidney-international.org
We should consider significant changes in the philosophy and role of
the coding professional and the CDI professional based on the recently
released AHIMA Updated Guidelines for Achieving a Compliant Query
Practice.
Guidelines for Achieving a Compliant Query Practice: Article citation:
AHIMA "Guidelines for Achieving a Compliant Query Practice." Journal of
AHIMA 84, no.2 (February 2013): 50-53.
“When a practitioner documents a diagnosis that does not appear to be
supported by the clinical indicators in the health record, it is
currently advised that a query be generated to address the conflict or
that the conflict be addressed through the facility’s escalation
policy.
What does this statement mean to Coding and CDI professional? Is it
now incumbent upon such professionals to ‘screen’ diagnoses clearly
written by a professional licensed to establish a diagnosis so that the
condition may be ‘confirmed?
If a facility were to take this stance, are uniform and standard
disease definitions accepted universally for this purpose? Are the
definitions used and cited in facilities to define, document and code
key conditions universally accepted by 3rd parties?
Regarding an escalation policy, how would (will) an MD react when a CDI
reviewer or coder issues a query to confirm a clearly documented
diagnosis that does not meet a facility-accepted universal definition of
acute renal failure, acute myocardial infarct, stroke, etc?
How do we respectfully ensure the documentation in our facilities is
‘reliable’, while at the same time respecting the latitude and
training of our physicians? Needless to say, this will be challenging.
A few other key and high-volume conditions are cited at the clo
se of
this statement– as I reviewed the various journals and studied the
disease definitions, I thought back to the now antiquated definition of
Acute Renal Failure I cited while obtaining my RHIA and the impact of
new research and medical definitions upon coding, medical research, and
epidemiological studies.
Based upon recent research, it occurs to me the medical profession now
diagnoses more often and MORE accurately conditions such as, but not
limited to, acute renal failure, sepsis, stroke and acute myocardial
infarcts than in the not too distant past. It seems obvious this will
impact us as we partner with physicians to ensure the complexity of care
is properly classified.
Universal definition of myocardial infarction
The term myocardial infarction reflects cell death of cardiac myocytes
caused by ischemia, which is the result of a perfusion imbalance between
supply and demand. The following diagnostic criteria should be met to
confirm a diagnosis of AMI:
*Source: Circulation. Published online August 24, 2012;
Download available @: http://circ.ahajournals.org/content/116/22/2634
Surviving Sepsis Campaign: International Guidelines for Management of
Severe Sepsis and Septic Shock: 2012
Infection, documented or suspected, and some of the following:
General variables
Fever (> 38.3°C)
Hypothermia (core temperature < 36°C)
Heart rate > 90/min–1 or more than two sd above the normal value for
age
Tachypnea
Altered mental status
Significant edema or positive fluid balance (> 20 mL/kg over 24 hr)
Hyperglycemia (plasma glucose > 140 mg/dL or 7.7 mmol/L) in the absence
of diabetes
Inflammatory variables
Leukocytosis (WBC count > 12,000 μL–1)
Leukopenia (WBC count < 4000 μL–1)
Normal WBC count with greater than 10% immature forms
Plasma C-reactive protein more than two sd above the normal value
Plasma procalcitonin more than two sd above the normal value
Hemodynamic variables
Arterial hypotension (SBP < 90 mm Hg, MAP < 70 mm Hg, or an SBP
decrease > 40 mm Hg in adults or less than two sd below normal for age)
Organ dysfunction variables
Arterial hypoxemia (Pao2/Fio2 < 300)
Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despite
adequate fluid resuscitation)
Creatinine increase > 0.5 mg/dL or 44.2 μmol/L
Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)
Ileus (absent bowel sounds)
Thrombocytopenia (platelet count < 100,000 μL–1)
Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or 70 μmol/L)
Tissue perfusion variables
Hyperlactatemia (> 1 mmol/L)
Decreased capillary refill or mottling
Distinguishing TIA from CVA
DWI-positive scans in TIA are common. According to the literature,
acute ischemic DWI lesions are present in 40.1% of patients with the
clinical diagnosis of a TIA (10 studies, 234/584 patients), a finding
that correlates with symptom duration. Only one of the studies involved
DWI performed within 24 hours of symptom onset. A recent study
estimated the epidemiologic impact of DWI-based diagnosis would result
in reduced annual TIA incidence (33%) and increased stroke incidence
(7%) in the United States.
P. D. Schellinger, R. N. Bryan, L. R. Caplan, J. A. Detre, R. R.
Edelman, C. Jaigobin, C. S. Kidwell, J. P. Mohr, M. Sloan, A. G.
Sorensen, et al. Evidence-based guideline: The role of diffusion and
perfusion MRI for the diagnosis of acute ischemic stroke: Report of the
Therapeutics and Technology Assessment Subcommittee of the American
Academy of Neurology. Neurology, July 13, 2010, 75(2): 177–185.
Coding Professionals & Compliance
Medicine and disease evolve quickly. For instance, I recall my senior
year in college when the physician teaching one of our Pathophysiology
Classes gave me the following assignment: “Define acute renal failure
(ARF), based on signs, symptoms, lab findings – be sure to cite
abnormal laboratory values”. I recall his exact words because of the
subsequent undertaking I was compelled to take in order to ‘define
ARF’.
Bear in mind this the year was 1989 – the tools of the Internet were
not available. Initially, I thought the assignment would be ‘not too
difficult’. I was incorrect. I went to the Medical Library, and I
must have found at least a dozen different ‘laboratory-defining’
definitions for ARF – all involving different levels of Serum BUN,
Creatinine and Potassium, and most with the key value pertaining to
Creatinine. Eventually, and after a lot of research and frustration,
I settled on a definition that included, among other key findings, those
below:
● Sudden rise in serum creatinine of >1mg/dl/day
● Rapid BUN elevation (greater than 20 mg/dl)
(I recall my professor accepted this definition, but I believe
he assigned this task to me for a reason – he wanted me to comprehend
the individual complexity and variation involved when one undertakes to
establish a ‘universal definition’ for a disease process).
We know now the definition I provided some time ago is outdated.
Consider the 2012 KDIGO Clinical Practice Guideline for Acute Kidney
Injury Definition (AKI means ‘acute kidney injury):
AKI is defined as any of the following (Not Graded):
● Increase in SCr by X0.3 mg/dl (X26.5 lmol/l) within 48 hours;
or
● Increase in SCr toX1.5 times baseline, which is known or
presumed to have occurred within the prior 7 days; or
● Urine volume o0.5 ml/kg/h for 6 hours.
Reference: http://www.kidney-international.org
We should consider significant changes in the philosophy and role of
the coding professional and the CDI professional based on the recently
released AHIMA Updated Guidelines for Achieving a Compliant Query
Practice.
Guidelines for Achieving a Compliant Query Practice: Article citation:
AHIMA "Guidelines for Achieving a Compliant Query Practice." Journal of
AHIMA 84, no.2 (February 2013): 50-53.
“When a practitioner documents a diagnosis that does not appear to be
supported by the clinical indicators in the health record, it is
currently advised that a query be generated to address the conflict or
that the conflict be addressed through the facility’s escalation
policy.
What does this statement mean to Coding and CDI professional? Is it
now incumbent upon such professionals to ‘screen’ diagnoses clearly
written by a professional licensed to establish a diagnosis so that the
condition may be ‘confirmed?
If a facility were to take this stance, are uniform and standard
disease definitions accepted universally for this purpose? Are the
definitions used and cited in facilities to define, document and code
key conditions universally accepted by 3rd parties?
Regarding an escalation policy, how would (will) an MD react when a CDI
reviewer or coder issues a query to confirm a clearly documented
diagnosis that does not meet a facility-accepted universal definition of
acute renal failure, acute myocardial infarct, stroke, etc?
How do we respectfully ensure the documentation in our facilities is
‘reliable’, while at the same time respecting the latitude and
training of our physicians? Needless to say, this will be challenging.
A few other key and high-volume conditions are cited at the clo
se of
this statement– as I reviewed the various journals and studied the
disease definitions, I thought back to the now antiquated definition of
Acute Renal Failure I cited while obtaining my RHIA and the impact of
new research and medical definitions upon coding, medical research, and
epidemiological studies.
Based upon recent research, it occurs to me the medical profession now
diagnoses more often and MORE accurately conditions such as, but not
limited to, acute renal failure, sepsis, stroke and acute myocardial
infarcts than in the not too distant past. It seems obvious this will
impact us as we partner with physicians to ensure the complexity of care
is properly classified.
Universal definition of myocardial infarction
The term myocardial infarction reflects cell death of cardiac myocytes
caused by ischemia, which is the result of a perfusion imbalance between
supply and demand. The following diagnostic criteria should be met to
confirm a diagnosis of AMI:
*Source: Circulation. Published online August 24, 2012;
Download available @: http://circ.ahajournals.org/content/116/22/2634
Surviving Sepsis Campaign: International Guidelines for Management of
Severe Sepsis and Septic Shock: 2012
Infection, documented or suspected, and some of the following:
General variables
Fever (> 38.3°C)
Hypothermia (core temperature < 36°C)
Heart rate > 90/min–1 or more than two sd above the normal value for
age
Tachypnea
Altered mental status
Significant edema or positive fluid balance (> 20 mL/kg over 24 hr)
Hyperglycemia (plasma glucose > 140 mg/dL or 7.7 mmol/L) in the absence
of diabetes
Inflammatory variables
Leukocytosis (WBC count > 12,000 μL–1)
Leukopenia (WBC count < 4000 μL–1)
Normal WBC count with greater than 10% immature forms
Plasma C-reactive protein more than two sd above the normal value
Plasma procalcitonin more than two sd above the normal value
Hemodynamic variables
Arterial hypotension (SBP < 90 mm Hg, MAP < 70 mm Hg, or an SBP
decrease > 40 mm Hg in adults or less than two sd below normal for age)
Organ dysfunction variables
Arterial hypoxemia (Pao2/Fio2 < 300)
Acute oliguria (urine output < 0.5 mL/kg/hr for at least 2 hrs despite
adequate fluid resuscitation)
Creatinine increase > 0.5 mg/dL or 44.2 μmol/L
Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)
Ileus (absent bowel sounds)
Thrombocytopenia (platelet count < 100,000 μL–1)
Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL or 70 μmol/L)
Tissue perfusion variables
Hyperlactatemia (> 1 mmol/L)
Decreased capillary refill or mottling
Distinguishing TIA from CVA
DWI-positive scans in TIA are common. According to the literature,
acute ischemic DWI lesions are present in 40.1% of patients with the
clinical diagnosis of a TIA (10 studies, 234/584 patients), a finding
that correlates with symptom duration. Only one of the studies involved
DWI performed within 24 hours of symptom onset. A recent study
estimated the epidemiologic impact of DWI-based diagnosis would result
in reduced annual TIA incidence (33%) and increased stroke incidence
(7%) in the United States.
P. D. Schellinger, R. N. Bryan, L. R. Caplan, J. A. Detre, R. R.
Edelman, C. Jaigobin, C. S. Kidwell, J. P. Mohr, M. Sloan, A. G.
Sorensen, et al. Evidence-based guideline: The role of diffusion and
perfusion MRI for the diagnosis of acute ischemic stroke: Report of the
Therapeutics and Technology Assessment Subcommittee of the American
Academy of Neurology. Neurology, July 13, 2010, 75(2): 177–185.
Comments
Paul Evans, RHIA, CCDS, CCS, CCS-P
San Francisco
(when I stea* ... errr ... borrow something, I like to know to whom to
give credit!)
Don
Cathy L. Seluke, RN, BSN, ACM, CCDS
Supervisor Clinical Documentation Compliance
MaineGeneral Medical Center
Augusta and Waterville, Maine
P. 207.872.1796
F. 207.872.1594
Cathy.Seluke@mainegeneral.org
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
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
NBrunson,RHIA,CDIP,CCS,CCDS
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
structure & format (all GOOD)
Thanks!
Don
We are all aware the RAC (and others) - see MedLearn for examples, has denied claims data based upon very clear MD documentation stating that 'even though condition XX is documented, clinical parameters are not met".
Dealing with this issue is going to require a lot of political capital, ACTIVE support from Executives, Senior Medical Staff, et al.
I am greatly concerned for the coders that finalize records - they will need great support (and far greater recognition as professionals) in order to deal with this particular development.
I also think AHIMA needs to acknowledge this new philosophy as professional 'coders' are educated in our universities, where in fact, we take a multitude of clinically-based courses.
Now, greater than ever, the still too-apparent divide still present with 'some', but not all, RN versus Coder, should cease within our profession.
If any of you have ever had to code 40 charts a day, (I have), you can appreciate the implications of this new development. I do not relish the idea of asking an MD to 'confirm' something such as encephalopathy, as one example. As someone stated earlier, some conditions are 'syndromes' and are based mostly upon MD judgement rather than hard data.
It will be somewhat 'easier' to vet conditions that are more clearly defined - such as AMI using the New Definitions, Acute Respiratory Failure with ABG, acute renal failure citing KDIGO, but I see much work ahead for us as we deal with this development.
Dealing with this apparent need for a coder to vet key statements, coupled with ICD-10, WILL lead to a decrease in coding productivity - I will say this is a certainty.
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
I have been following the dialogue and I would like to add a few comments.
First, as CDI RN's we are expected to bring a clinical perspective to the chart review and coding process.
Secondly, since we are visible presence here in our facility, we can discuss cases with the physicians more readily than the coders who are based off-site. I have had the occasion to sit with a physician and share with him that all of the providers who saw this patient documented, "hyperglycemia" however he used the diagnosis "DKA". I was very polite in asking him if he had observed other indicators some of the other providers may have missed. When we looked together, he stated that it was actually hyperglycemia and he was pleased with the interaction. I believe having a visible CDI presence is extremely important.
We actually have a phone conversation with our coding team manager once a month to help foster the coding/RN relationship as well as learn from their expertise.
When I provide physician education in a group setting, I always make sure they understand, I am asking questions as a nurse based on the clinical indicators I have seen or lack thereof. I also remind them and my nurses that they all went to different schools and have been taught to look at a patient's picture differently.
So to add on to the notes, we need to be a team....RN's, coders and physicians.
Thank you,
Lisa Romanello, RN,BSN,FNS,CCDS
Manager, Clinical Documentation Improvement Specialist
Quality Department
CJW Medical Center
804-228-6527
However, my point is that some 'coders', with the proper background (accredited) can also perform concurrent chart reviews. Does not the CCDS credential prove the holder of the credential is qualified and accredited by ACDIS?
Some RNs do this well...some not - just as with 'some' coders. Some do it well, some not.
It depends upon the individual.
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
I agree. The take away I was trying to share was the need for a "team" effort. I have a great respect for the coders and probably could not do the job they are expected to do. However, I really believe a team of coders, RNs and physicians willing to participate in our efforts is the ticket to success. We each bring value to the table.
Lisa Romanello, RN,BSN,FNS,CCDS
Manager, Clinical Documentation Improvement Specialist
Quality Department
CJW Medical Center
804-228-6527
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