queries for lack of clinical indicators?
Hi all,
Have you read Cheryl’s recent blog post regarding querying for lack of clinical indicators? I found it very insightful and am planning on using it in further conversations with our physician liaison regarding queries for clinical indicator. Immediately after the Query Brief came out in February I approached our leadership about establishing a process for queries for lack of clinical indicators. They rejected the idea because our physician liaison was very uncomfortable with CDI/coding ‘questioning’ physician judgment. I dropped it with the intention of revisiting the idea soon.
In the meantime, I know that many other facilities are currently submitting this type of query. I am curious how this is working for you and in what instances these are being submitted? Do these queries get routed through a manager or potentially a physician? The blog post implies that this type of query should be quite rare and only be submitted when there really is nothing in the record to support dx. A query should not be placed if the provider appears to be using different criteria to make a dx than CDI/Coding would, etc.
Recently, I have fielded several calls from coders asking if I can submit a query to validate a dx that is stated in the discharge summery. Often there are indicators in the record but it may not be as clear cut as the coder would like. I am unsure whether a query is warranted in those scenarios.
A couple examples:
1. A patient presents with tachycardia, hypotension, and leukocytosis and the MD states in the H&P that this is likely sepsis or an abdominal process. In the progress notes for the next several days the provider states Shock: metabolic +/- septic. The patient does have pneumonitis and angiitis documented but also turns out to have metastatic breast cancer. The discharge summery states Septic shock. The coder does not think this dx is right and would like to query for the validity of the septic shock.
2. Patient is admitted with chest pain (recent MI) and also had a UTI with fever. For the 3 day LOS sepsis is not in the record. However, in the d/c summery the physician states that the patient has SIRS 2/2 UTI. The coder does not want to code this dx and would like to query for the validity of the dx.
Thoughts on this subject?
http://blogs.hcpro.com/acdis/2013/08/qa-querying-for-clinical-validation-of-a-diagnosis/
Thanks everyone!
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
Have you read Cheryl’s recent blog post regarding querying for lack of clinical indicators? I found it very insightful and am planning on using it in further conversations with our physician liaison regarding queries for clinical indicator. Immediately after the Query Brief came out in February I approached our leadership about establishing a process for queries for lack of clinical indicators. They rejected the idea because our physician liaison was very uncomfortable with CDI/coding ‘questioning’ physician judgment. I dropped it with the intention of revisiting the idea soon.
In the meantime, I know that many other facilities are currently submitting this type of query. I am curious how this is working for you and in what instances these are being submitted? Do these queries get routed through a manager or potentially a physician? The blog post implies that this type of query should be quite rare and only be submitted when there really is nothing in the record to support dx. A query should not be placed if the provider appears to be using different criteria to make a dx than CDI/Coding would, etc.
Recently, I have fielded several calls from coders asking if I can submit a query to validate a dx that is stated in the discharge summery. Often there are indicators in the record but it may not be as clear cut as the coder would like. I am unsure whether a query is warranted in those scenarios.
A couple examples:
1. A patient presents with tachycardia, hypotension, and leukocytosis and the MD states in the H&P that this is likely sepsis or an abdominal process. In the progress notes for the next several days the provider states Shock: metabolic +/- septic. The patient does have pneumonitis and angiitis documented but also turns out to have metastatic breast cancer. The discharge summery states Septic shock. The coder does not think this dx is right and would like to query for the validity of the septic shock.
2. Patient is admitted with chest pain (recent MI) and also had a UTI with fever. For the 3 day LOS sepsis is not in the record. However, in the d/c summery the physician states that the patient has SIRS 2/2 UTI. The coder does not want to code this dx and would like to query for the validity of the dx.
Thoughts on this subject?
http://blogs.hcpro.com/acdis/2013/08/qa-querying-for-clinical-validation-of-a-diagnosis/
Thanks everyone!
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
Comments
Example two: May be questionable as the example does not indicate that 'some' of the conditions necessary for Sepsis or SIRS due to UTI are/were clinically present. Therefore, I understand reluctance to code and verification may be wise. Would use a query to confirm with citations from Surviving Sepsis that we are all so familiar with.
UTI and Fever not convincing evidence of SIRS or Sepsis.
Personally, I like to use the typical vital signs we all know so well, as well as Lactic Level, WBC and convincing evidence of "left shift".
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
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
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
You can call me and I will explain what we do! It has been successful.
Thanks!
Jamie Dugan RN
Baptist Health System
Jacksonville, Fl
Office 904-202-4345
Cell 904-237-7253
"I guess where my confusion is that I feel like there is a potential that some staff members (CDI and coding) may be inclined to clarify the documentation constantly if they don’t feel the medical record includes enough clinical information. This seems very grey to me. What is ‘enough’? For example, if the provider documents renal failure, we have a creatinine bump, we give fluids, monitor, etc, but it doesn’t meet RIFLE criteria? Or, the patient has an infectious source and a fever but no other sepsis indicators and sepsis is documented? Do we query for clinical indicators there to get the MD to r/o that diagnosis. Or, is this primarily for things like the examples in the brief. Ex: documentation of hypernatremia when the Na+ is 120 or documentation of ‘no surgical complications’ when there was an interoperative laceration."
The examples in the ACDIS/AHIMA brief were very obvious and things we (prior to this) would have just spoke to the MD about to fix in their note. But when we are talking about clinical validation of nebulous dx like Sepsis, respiratory failure, encephalopathy, malnutrition, renal failure, etc, it gets trickier.
Thanks everyone!
Jill, I will be calling. I am in Ak so our times zones are very different and I got caught up today.
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