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
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
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
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
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
Mary L. Snook RN-BC
Clinical Documentation Specialist
Medical Information Services
Hemiparesis by definition is weakness of one side of the body. Hemiplegia is paralysis. We were asking for hemiparesis following a major stroke.
hemiparesis unspecified and hemiplegia unspecified have the same code,
342.9
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
Janice
Janice Schoonhoven RN, MSN, CCDS
Clinical Documentation Integrity
Manager- PeaceHealth Oregon West Network
Mary L. Snook RN-BC
Clinical Documentation Specialist
Medical Information Services
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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
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
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]
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
recently.
Cindy Pritchett, RN, BSN, CCDS
MedPartners Consultant
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.
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
Janice
Janice Schoonhoven RN, MSN, CCDS
Clinical Documentation Integrity
Manager- PeaceHealth Oregon West Network
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!
Cindy
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
Vanessa
Claudine Hutchinson RN (CDI)
The Children's Hospital at Saint Francis
chutchinson@saintfrancis.com
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
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
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
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?
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
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
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
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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?
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
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 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.
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
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
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
Claudine Hutchinson RN (CDI)
The Children's Hospital at Saint Francis
chutchinson@saintfrancis.com
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.
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