RE: [MARKETING] RE:good tip as we approach clinical indicator queries...
Yes, Sorry Robert. Clinical indicators.
We are also expanding our process to include review of the patient through discharge and placing of all retro queries. My concern is that I have already had occasions where coding/CDI wants to query on something that is justified by the MD in some form, similar to the malnutrition issue here (CDI uses ASPEN but the provider may make his/her determination on something else). It is my understanding that these queries should be fairly rare. I am concerned now that we have this process in place that there may be some coders/CDI that want to ask MD's to justify diagnoses unnecessarily.
I keep going back to Cheryl's response to a prior question:
"There is a difference between the criteria we, as CDI specialists/coders, must use to support when issuing a query compared to those the provider uses to make a diagnosis. I know this seems like a subtle distinction, but I think this is what was meant by not questioning the provider's medical judgment. We are not "armchair quarterbacks" validating the diagnoses determined by the provider; rather we are ensuring there is a basis for making such a determination within the health record, not evaluating the quality of those clinical indicator(s).
Yes, there is a lot of pressure to only report those diagnoses that can withstand audit; however, we must abide by coding guidelines and industry standards as defined by the practice briefs so we balance when a query is genuinely warranted and when it is not. We don't want to brow beat providers into adding documentation we think should be in the record or discount valid diagnoses because we disagree with the criteria used to define the condition. To resolve this conflict (and to help facilitate physician support for CDI program efforts) many facilities have asked for physician assistance in developing query guidelines and identifying appropriate clinical indicators for frequently queried diagnoses such as malnutrition, acute renal failure, and the like."
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
We are also expanding our process to include review of the patient through discharge and placing of all retro queries. My concern is that I have already had occasions where coding/CDI wants to query on something that is justified by the MD in some form, similar to the malnutrition issue here (CDI uses ASPEN but the provider may make his/her determination on something else). It is my understanding that these queries should be fairly rare. I am concerned now that we have this process in place that there may be some coders/CDI that want to ask MD's to justify diagnoses unnecessarily.
I keep going back to Cheryl's response to a prior question:
"There is a difference between the criteria we, as CDI specialists/coders, must use to support when issuing a query compared to those the provider uses to make a diagnosis. I know this seems like a subtle distinction, but I think this is what was meant by not questioning the provider's medical judgment. We are not "armchair quarterbacks" validating the diagnoses determined by the provider; rather we are ensuring there is a basis for making such a determination within the health record, not evaluating the quality of those clinical indicator(s).
Yes, there is a lot of pressure to only report those diagnoses that can withstand audit; however, we must abide by coding guidelines and industry standards as defined by the practice briefs so we balance when a query is genuinely warranted and when it is not. We don't want to brow beat providers into adding documentation we think should be in the record or discount valid diagnoses because we disagree with the criteria used to define the condition. To resolve this conflict (and to help facilitate physician support for CDI program efforts) many facilities have asked for physician assistance in developing query guidelines and identifying appropriate clinical indicators for frequently queried diagnoses such as malnutrition, acute renal failure, and the like."
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