ABL Anemia/Clinical Indicator Query
For those querying for clinical indicators of documented diagnoses. If you had a patient with documented Acute Blood Loss Anemia s/p surgery but they never had an Hgb below 10, received no transfusions, and we did not repeat the H/H after the initial draw on Post-op Day #1, would you query? Or, is this more an issue of it being at the MDs discretion since this patient did have a dip in H&H and did have blood loss?
I am sorry, I feel like I keep asking questions related to queries for clinical indicators. I feel responsible to my staff to have the answers and I am still working out in my head how this process should work.
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
I am sorry, I feel like I keep asking questions related to queries for clinical indicators. I feel responsible to my staff to have the answers and I am still working out in my head how this process should work.
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
Tara RN, CCDS
It was coded and denied. Our coding manager has scheduled time to go over it and I am trying to figure out what I think the right move would have been...
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
I feel this is an issue that coders experience quite often. The physician documents a diagnosis but it does not meet the criteria for reporting. If the diagnosis is not treated/monitored or extends length of stay, it should not be coded even if documented. I don't believe that I would query.
Jolene File,RHIT,CCS,CPC-H,CCDS
Documentation Improvement Specialist-Coder
Hays Medical Center
jolene.file@haysmed.com
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Some References follow - in particular, one I compiled for MVP - Concept applicable to many potential diagnoses.
MVP meets the criteria for a secondary diagnosis if the physician documents the condition, evaluates the condition, or monitors the condition in some fashion that meets the criteria set forth in Coding Clinic such that the condition qualifies in terms of any of the following:
• Clinical Evaluation
• Therapeutic Treatment
• Further evaluation by diagnostic studies, procedures or consultation
• Extended LOS
• Increased nursing care and/or other monitoring
As an example, a patient presents for a planned spinal fusion. During the H&P, the physician documents signs of MVP. The patient is referred to a cardiologist who orders an echocardiogram. The cardiologist documents the patient has moderate MVP – the condition is coded.
Clinical Evaluation Defined
Clinical evaluation means the medical staff is aware of the condition and is evaluating it in terms of evaluation, testing, consultations, and clinical observation of the patient’s condition and/or the existence of the condition affect the types or choices of treatment rendered to the patient.
MVP is not coded if:
The chart mentions this condition without further indication the condition is reportable. A physical examination and a history is a ‘routine’ part of every hospital admission. The mere existence of any condition does not mean the condition is always reportable.
Per Faye Brown, 2006, “Codes should not be assigned for conditions that do not meet UHDDS criteria for reporting. For example, diagnostic reports often mention such conditions such as hiatal hernia, atelectasis, and right bundle branch block with no further mention to indicate any relevance to the care given. Assigning a code is inappropriate for reporting purposes unless the physician provides documentation to support the condition’s significance for the episode of care”
The mention of mild or asymptomatic MVP does not “usually” meet the definition of a reportable condition. In addition, some coders feel it is appropriate to report MVP merely because the record may state something such as: “Echo showed mild MVP”. However, this is NOT a diagnostic statement and this practice is contradicted by Coding Clinic.
AHA Coding Clinic for ICD-9-CM, 1Q 2005, Volume 22, Number 1, Page 96
B.Abnormal Findings
Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added.
Per some recent QIO denials, Coding Clinic, 1st Qtr, 2005, states “other diagnoses” are reported as additional conditions if they affect the patient’s case. This requires clinical evaluation or therapeutic treatment or diagnostic procedures, or extended length of stay, or increased nursing care and/or monitoring. The QIO has recently stated in some denials to LMS that valvular disorders not meeting this criteria are “incidental findings not clinically significant” and it is inappropriate to report such conditions.
Coding Clinic, 2Q, 1990
Abnormal findings (laboratory, X-ray, pathologic, and other diagnostic results) are not coded and reported unless the physician indicates their clinical significance. If the findings are outside the normal range and the physician has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the physician whether the diagnosis should be added.
The coder should not arbitrarily add an additional diagnosis to the final diagnostic statement on the basis of an abnormal laboratory finding alone. To make a diagnosis on the basis of a single lab value or abnormal diagnostic finding is risky and carries the possibility of error.
It is important to remember that a value reported either lower or higher than the normal range does not necessarily indicate a disorder. Many factors influence the value of a lab sample. These include the method used to obtain the sample (for example, a constricting tourniquet left in place for over a minute prior to collecting the sample will cause an elevated hematocrit and potassium level), the collection device, the method used to transport the sample to the lab, the calibration of the machine that reads the values, and the condition of the patient. An example is a patient who because of dehydration may show an elevated hemoglobin due to increased viscosity of the blood.
Example 1: A low potassium level finding treated with intravenous or oral potassium is clinically significant and should be brought to the attention of the physician if no diagnosis has been documented.
Example 2: A hematocrit of 28 %, even though asymptomatic and not treated, may have been evaluated by the physician with serial hematocrits. Because this is outside the range of normal laboratory values and has been further evaluated, it is significant enough to ask the physician whether an associated diagnosis should be documented.
Example 3: A routine preoperative chest X-ray on an elderly patient reveals collapse of the vertebral body. The patient was asymptomatic and no further evaluation or treatment was carried out. This is a common finding in elderly patients and is probably insignificant for this episode.
Example 4: In the absence of a cardiac problem, an isolated electrocardiographic finding of bundle branch block is ordinarily not significant, whereas a finding of a Mobitz II block may have important implications for the patient's care and would warrant asking the physician whether it should be reported for this admission.
Example 5: Incidental findings on X-ray such as asymptomatic hiatal hernia or diverticulosis should not be reported unless further evaluation or treatment is carried out.
Codes from section 790-796, Nonspecific abnormal findings, should be assigned only when the physician has not been able to arrive at a diagnosis based on an abnormal finding, but considers it clinically significant enough to list in the final diagnostic statement.
Example 6: The physician lists an abnormal sedimentation rate, 790.1, on the face sheet and has been unable to make a definitive diagnosis during the hospitalization.
Example 7: An abnormal pap smear of cervix, 795.0, is listed in the final diagnostic statement.
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