Feedback please

I received an email and a follow up call from one of our hospitalists (this is the same physician who will write a PARAGRAPH explaining patient's s/s of CHF and the treatment he is providing as well as the patient's response to treatment, but will not add the word acute, decompensated, or exacerbated).

Dr D emailed me to ask the difference between right sided weakness and hemiparesis. My response was that in the coding world, right sided weakness is a sign/symptom of a diagnosis, while hemiparesis is a diagnosis. He called me to discuss his question this morning insisting that they are one and the same. I explained that in coding, one is a diagnosis and one describes a diagnosis. One is coded as a diagnosis and one as only a symptom.
I also pointed out that the diagnosis of hemiparesis is considered by CMS to be a comorbid condition since additional resources (physical and occupational therapies as well as equipment and nursing care) are utilized in treating the patient. Hemiparesis is also a strong supporting diagnosis for a skilled nursing or rehab level of care at discharge.
He ended the conversation by saying to consider that query answered (weakness being his answer).
I had sent a documentation tip email to Dr H who is over our hospitalist group regarding this diagnosis in September (He requested I do this each month with the most frequently written query). His response was that we would not be out of line querying for the diagnosis and that he had spoken with the 2 lead hospitalists (one of whom is Dr D) and that they would share the information with the group.

Thoughts? Better way to explain? Lost cause? Am I being unreasonable? Find a new career?

Sharon Cole, RN, CCDS
CDI Specialist Team Leader
254-751-4256
Sharon.cole@phn-waco.org



Comments

  • edited April 2016
    Sharon,
    Definitely DON'T change careers...you're doing a great job! I tell my group here all the time that we just have to be calm, consistent voices of reason and the message will land eventually.
    I have found it helpful to do a quick reminder sometimes that their diagnosis have to 'match' the wording that Medicare has assigned. Even though as nurses we understand the descriptions, as CDS's we function as their "CPA's" for the Medicare lingo, helping them match up the needed terminology. We don't expect them to memorize all this-we are there to help!
    Hang in there-
    Janice

    Janice Schoonhoven RN, MSN, CCDS
    Clinical Documentation Integrity
    Manager- PeaceHealth Oregon West Network


  • edited April 2016
    I agree, hang in there. It sounds like you are doing a great job. I also use the "medicare lingo" line also and "you know, you bill medicare also, right" They usually laugh and then are more receptive....


    Mary A Hosler MSN, RN
    Clinical Documentation Specialist
    Alumnus CCRN
    McLaren Bay Region
    1900 Columbus Ave.
    Bay City, Michigan 48708
    (989) 891-8072
    mary.hosler@mclaren.org




  • Sharon,
    I think your response was perfect!

    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

  • edited April 2016
    Weakness is not paralysis - a main debate point



  • edited April 2016
    We are getting ready to open a new Neuro unit next week, albeit a small one. I will be rounding daily in this unit and the Neurologist will be there to answer any verbal queries/questions I may have. Does any one have any specific comorbidities that they query for in this DRG in addition to Hemiparesis? I am just looking for Neurological CC's/MCC's. I also know that Encephalopathy is another diagnosis that can add a CC or MCC. It can require further investigation in addition to the Hemiparesis. Thank you for any ideas you may have.

    Mary L. Snook RN-BC
    Clinical Documentation Specialist
    Medical Information Services
  • edited April 2016
    Thanks everyone.

    Hemiparesis by definition is weakness of one side of the body. Hemiplegia is paralysis. We were asking for hemiparesis following a major stroke.
  • edited April 2016
    Sorry, what tripped me up is that per the ICD-9-CM code book index,
    hemiparesis unspecified and hemiplegia unspecified have the same code,
    342.9




  • This was exactly what I was going to suggest (plus a few diagnoses). great response :)

    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

  • edited April 2016
    I'll throw in sensory or left-sided neglect as well.
    Janice
    Janice Schoonhoven RN, MSN, CCDS
    Clinical Documentation Integrity
    Manager- PeaceHealth Oregon West Network


  • edited April 2016
    Thank you very much for your time and assistance.

    Mary L. Snook RN-BC
    Clinical Documentation Specialist
    Medical Information Services
  • edited April 2016
    --001a11c1d8d21daf4104e9e5f6de
    Content-Type: text/plain; charset=ISO-8859-1

    Hi Sharon -

    Just wondering how involved your Chief Medical Officer is with your CDI
    program? Has administration supported your team by putting a "chain of
    command" in place to support your CDI Specialists when they face the "brick
    wall"? My experience has been that those organizations that truly have
    administrative buy-in are the organizations that have strong,
    successful programs.

    Hats off to you for not giving up!! I think your response was extremely
    concise and clear.......you have just met one of the great challenges
    within our specialty - the physician that implies CDI Specialists are
    entirely responsible for CMS guidelines/rules. Don't give up - at least
    you planted the seed. Just keep watering it and who knows - he may
    surprise you someday!

    Congrats on a job well-done - even if it ended in frustration.

    Cindy Pritchett
    MedPartners CDI Consultant

  • edited April 2016
    Thank you, We do try:)
    Sharon

  • edited April 2016
    Hi Sharon,
    I have had discussions similar to this with physicians in the past. One point that I would like to make is that I explain that when they use a symptom or unspecified diagnosis, these are often the same diagnoses that are treated as stable, chronic conditions in the outpatient setting. These unspecified diagnoses or symptoms are under the scrutiny of auditors such as the recovery auditors. In order to help establish the medical necessity for the inpt stay. I also let them see all the RAC denials they have for medical necessity which is also reported to administration.
    Kathy Shumpert

  • Also, hemorrhage in an ischemic stroke secondary to adverse effect of tissue plasminogen activator.

    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

    [cid:image001.jpg@01CED4B3.9DA71390]

  • edited April 2016
    Good point Kathy, thanks!

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Tuesday, October 29, 2013 3:55 PM
    To: Cole, Sharon (PHN/Waco)
    Subject: Re: [cdi_talk] Feedback please


    Hi Sharon,
    I have had discussions similar to this with physicians in the past. One point that I would like to make is that I explain that when they use a symptom or unspecified diagnosis, these are often the same diagnoses that are treated as stable, chronic conditions in the outpatient setting. These unspecified diagnoses or symptoms are under the scrutiny of auditors such as the recovery auditors. In order to help establish the medical necessity for the inpt stay. I also let them see all the RAC denials they have for medical necessity which is also reported to administration.
    Kathy Shumpert

  • edited April 2016
    Cerebral dysfunction also codes to an MCC - just learned this one
    recently.

    Cindy Pritchett, RN, BSN, CCDS
    MedPartners Consultant

  • edited April 2016
    Can you share what the criteria is that defines cerebral dysfunction?

  • edited April 2016
    I have to apologize for throwing that one out w/o the supporting clinical
    markers/triggers. I am researching this term myself at present. Would
    love to hear input from anyone who works with this regularly. I don't have
    access to a neurologist easily at my current assignment, but think that
    would be the best place to start.

    The current article I am reading describes cerebral dysfunction in the
    post-op CABG pt. Below is the link to the article:

    http://link.springer.com/article/10.1007/s00540-013-1699-0#page-2

    This is just the beginning of my review so if anyone finds anything
    interesting please share.

  • edited April 2016
    I agree Karen - that's excellent advice. I presented "Encephalopathy &
    Other Brain-related SOI" at the 2013 ACDIS conference, but did not address
    this term in my presentation. I was unfamiliar with the coding pathway
    that results with this dx.

    I support "caution" with it too - and I agree that it would be a reasonable
    option for an encephalopathy query.

    Cindy Pritchett, RN, BSN, CCDS
    MedPartners Consultant

  • edited April 2016
    Cerebral dysfunction will not be an I-10 option. We have chosen here to continue educating and using encephalopathy rather than bringing in a term the providers would then need to 'unlearn.'

    Janice
    Janice Schoonhoven RN, MSN, CCDS
    Clinical Documentation Integrity
    Manager- PeaceHealth Oregon West Network



  • Start educating the providers about documenting whether the neurological deficits (hemiparesis/hemiplegia) affect the "dominant" versus "non-dominant" side. We already have specific codes for this in ICD-9, but it is a dominant feature of ICD-10. No time like the present for giving docs the "concepts" that will apply to many codes.

    Also provide education to the occupational, physical, speech therapists that they should document these findings in their assessments and notes.

    Why is this important? If a person has deficits on the dominant side, their rehab will be more complicated, right? Just think of how hard it is to do anything with your non-dominant hand or foot!
  • edited April 2016
    We would code the sepsis at our institution.
    Cindy

  • If sepsis criteria were met and 2 physicians stated (severe) sepsis, it sounds like it should have been coded. Would coder not code it because it wasn't in DC Summary? If so, then I think coder should have queried.
    This is a current discussion at our facility of whether coding should code any diagnoses that are not mentioned in DC Summary; our CDI dept. says it SHOULD!
    Good luck.

    Claudine Hutchinson RN (CDI)
    The Children's Hospital at Saint Francis
    chutchinson@saintfrancis.com

  • edited April 2016
    Thanks all. :) I seem to be having a difficult time convincing the coders (and the Manager) that they should be doing queries at all.
    Vanessa

  • And I should add: our CDI dept. is educating/reinforcing with physicians on importance of consistent documentation through record (carrying diagnoses thru the record) and listing all diagnoses in the DC Summary. Ongoing battle, but it's job security. :-)

    Claudine Hutchinson RN (CDI)
    The Children's Hospital at Saint Francis
    chutchinson@saintfrancis.com

  • Best Practice - Sepsis is stated in Summary as POA, but resolved with treatment, leaving no doubt it should be reported. (Also, per JCAHO, 'all significant" conditions are stated in the summary).

    Coder should have 'at least' queried to confirm was POA. However, coders are becoming 'cautious' as some 3rd parties are denying conditions in such situations

    PERSONALLY, I would code this w/o a query.

    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

    evanspx@sutterhealth.org

  • edited April 2016
    I agree. I would have no problem coding this without a query. I look at it this way; If this dx was to be denied by the insurer, could I defend it clinically? In this case if indicators are met and 2 MD's documented it, I believe I could. There is no guideline that states that the Pdx (or any dx) must be in the d/c summery.

    However, if the coder was not comfortable, the should query. Dx should not simply be ignored in my opinion.

    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

  • Also, per updated AHIMA/ACDIS guidelines, conditions stated, but perhaps that need to be confirmed, should garner a query. Agree: should not be ignored.

    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

    evanspx@sutterhealth.org




  • Ideally, if the physician was available we would have visited with them and stressed the importance of documenting ALL significant dx's pertaining to the patients stay and asked them to clarify this on their discharge summary.
    If the physician wasn't available I would have coded sepsis.
    But I do have a question.... If you have documentation specialists why are the coders querying? Isn't that their job to clarify any documentation ambiguity on the front end before it even gets to coding?
  • Since the chart stated "Sepsis, Resolved", I would not query concurrently....at the time of concurrent review, one does not know the content of the dictated summary.

    I would code any condition meeting generally accepted clinical criteria that is also explicitly stated as resolved w/o a query.

    See this quite often with ATN, acute Respiratory Failure, hyponatremia, encephalopathy, etc.

    (If we wait for the perfect summary - we will probably code nothing) :)



    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

    evanspx@sutterhealth.org


  • edited April 2016
    I agree with those who said it could/should be coded especially with the statement of "sepsis resolved". Clinical criteria met, treatment rendered and outcome stated. A query should have been generated at the very least.

    There are times when sepsis (or any diagnosis) is documented at sometime during the admission and then just kind of falls off the record. If that were the case, a query may be a good idea.

    Personally I do not feel a fear of 3rd party reviews is a good reason to not code a well-documented and clinically supported diagnosis. At the most that fear should just reinforce being mindful of coding rules and guidelines. As Katy said, if the record supports the argument for a documented diagnosis, it should be coded.

    Just my 2 cents worth -

    Sharon Salinas, CCS
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    ssalinas@barlow2000.org
  • But I do have a question.... If you have documentation specialists why are the coders querying? Isn't that their job to clarify any documentation ambiguity on the front end before it even gets to coding?


    That’s a good question. CDI thought the sepsis was clear at the time of initial review, and unfortunately we have a small program and often do not get to do follow up reviews unless there is an issue from the beginning. I am in the process now of reconciling Jan 2014 cases, to try to document how often the DRG is affected after CDI review and justify more staff :)
    Vanessa
    CONFIDENTIALITY NOTICE: This communication and its attachments may contain confidential or privileged information intended solely for the use of the individual or entity to whom it is addressed. If you are not an intended recipient, you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it (or any portion of the contents) or the attachments is strictly prohibited. If you have received this communication in error, please contact the sender and immediately destroy all copies of the communication and attachments. Thank you.
  • Who's to say that the CDI staff didn't address this on "front end" one time or numerous times (such as speaking to physician/physician-resident education, phone calls, emails, posters, etc.)? Maybe they don't have physician advisor/champions to assist with problematic documentation areas/difficult physicians (physicians without "buy-in"), etc. Maybe there is only 1 CDI person (as in my case) and if chart had a MCC then they didn't get to rereview that chart due to other priorities/caseload/job responsibilities, etc. (CDI programs can have different focuses~ such as complete & very specific documentation/capture all diagnoses on each case, find cc/mcc on each case only, etc.).

    Claudine Hutchinson RN (CDI)
    The Children's Hospital at Saint Francis
    chutchinson@saintfrancis.com


    Ideally, if the physician was available we would have visited with them and stressed the importance of documenting ALL significant dx's pertaining to the patients stay and asked them to clarify this on their discharge summary.
    If the physician wasn't available I would have coded sepsis.
    But I do have a question.... If you have documentation specialists why are the coders querying? Isn't that their job to clarify any documentation ambiguity on the front end before it even gets to coding?


  • edited April 2016
    There will always be need for retro queries regardless of the breadth of a CDI program. Different reviewers have varying comfort levels, understanding of the guidelines, clinical knowledge, etc. We try to cover all inpatients and we still need retro queries occasionally.
    In this case, I would not have queried concurrently because I think the documentation was sufficient. But if the coder felt otherwise, they should have contacted the CDI for input and/or written a query rather than just leaving out a very important dx.

    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

  • Yes Katy I agree with you on your statement all the way! I mean CDI cannot/ or for that matter the coder either, see everything-and I would not have queried-if our coders are uncomfortable and feel something warranted a query before/or after the fact they will email me or just do it themselves-we have to be able to communicate-and not have knee-jerk reactions on who should do what!! This thing is going to get harder-with the denials and we will ALL have to work together and stand up to these denials-though we might as throw in the towels now. But we have always ruled on the fact if it was documented it cannot be taken away-if need be just clarify.

    Deb

    Debra Stewart RN, BSN
    Clinical Documentation Specialist
    Sentara/Halifax Regional Hospital
    South boston, va. 24592
    (434)-517-3317 Work
    (434)-222-9884 Cell

  • I didn’t mean to offend anyone…..
    I agree there will always be the need for retro queries.
    If the facility wants their CDI’s main focus as identifying CC’s and MCC’s on each case and to move on then from that perspective once that’s identified they are done with the encounter.
    Until recently this is how they were done at our facility but there were also some increasing problems.
    As our hospitalist program was expanding with more physicians we were seeing more and more ambiguous documentation and sometimes conflicting documentation throughout the chart…or just before discharge.
    Since we were expanding we were having more physicians rotating through this meant each physician was off service for longer stretches of time which caused coding queries to take longer and longer to be resolved. Oftentimes a query was taking two to three weeks or longer because that physician might not be back on service until then.
    …I don’t know the work flow for other facilities but here once the encounter is in a discharged but un-coded account wq the expectation/goal is for that encounter to be released within five days.
    If coding had a query after discharge and the physician was not scheduled to be back on rotation for two weeks or more that $ was sitting well past the five days rather than moving on to billing.
    After a process improvement plan was initiated the new process is for the chart to be reviewed at admission as well as at the time of discharge to clarify and solve any issues while the physician is still on service.

    Is this perfect, no. Is this going to work 100% of the time, of course not. Nothing works 100% but we are working towards having less encounters waiting on a query after discharge. Again, it’s a goal.
  • edited April 2016
    I wasn't offended in any way, and I appreciate the discussion everyone!



    Vanessa Falkoff RN
    Clinical Documentation Coordinator
    University Medical Center of Southern Nevada
    1800 W Charleston Blvd
    Las Vegas, NV
    vanessa.falkoff@umcsn.com
    office 702-383-7322

    Compassion * Accountability * Respect * Integrity
  • No offense taken - great question and great discussion of an ongoing and vexing issue.

    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

    evanspx@sutterhealth.org



  • edited April 2016
    Agreed :)

    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
  • Ditto {agreed :) }

    Claudine Hutchinson RN (CDI)
    The Children's Hospital at Saint Francis
    chutchinson@saintfrancis.com

  • From July 2012 MLN Matters® Number: SE1121 Revised

    The failure of the attending physician to mention a
    consultant’s diagnosis is not a conflict. So, if the consultant documents a diagnosis and the attending physician doesn’t mention it at all, it is acceptable to code it. A conflict occurs when 2 physicians call the same condition 2 different things – for example, the attending physician documents a sprained ankle and the orthopedist refers to the same injury as a fracture.

    If you have any questions, please contact your FI or A/B MAC at their toll-free number, which may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html on the CMS website.
  • edited April 2016
    Loved it when this was issued. It confirms the practice many coders (at least this coder) have been doing forever. If the coding guidelines, documentation, clinical data and treatment supports it and it is not a conflict, I code it. If I can intelligently argue for its inclusion, I code it. If it meets the definition of 'other diagnosis', I code it.

    I know about 3rd party reviewers, RACs etc. I still refuse to not code a legitimate diagnosis out of fear.

    Sharon Salinas, CCS
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    ssalinas@barlow2000.org
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