Other departments and Queries

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
Hi all,

I have a question about other departments using 'queries' to ensure their dx are included in the record. For example, at our facility our nutrition team used to have a process in place (prior to the implementation of our program) in which they placed a paper query on the record when they wrote their note if they made a dx of malnutrition. The idea was that this paper identified that they had made a dx, asked the MD to confirm and sign, and then the dx was in the record. When we started our program we asked them to instead contact us and we would place the query, track it, and make sure it was responded to. Since then we have refined the process to make us more automated and it works great.

However, I have recently been made aware that infectious disease is placing queries to confirm CAUTI's and there is talk of WCON's doing something similar for pressure ulcers...

The problem is that their queries present the clinical criteria of a CAUTI and then asks "Based on your medical judgment and review of the clinical indicators do you agree that this is a Catheter Associated Urinary Tract Infection?" Clearly this is not compliant from a CDI perspective but they are not CDI. Any thoughts on this? Any other hospitals coming across this? And, for those of you on the Coding side of this, would you code a CAUTI if the MD responded positively to this query?



It's an awkward situation since it's not a CDI query and I honestly am not sure what to think/do....

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

  • annnd2009@gmail.comannnd2009@gmail.com
    edited April 2016

    I think the practice brief holds everyone to compliance standards
    regardless of title.
    Ann

    Sent from my iPhone

  • debra.stewart@halifaxregional.comdebra.stewart@halifaxregional.com
    edited April 2016
    Well Katy, we have not had that happen in our facility, so don't know what to say about that. It certainly is leading, but when we were training for CDI, I do believe I remember them saying a nurse or anyone else could ask for a diagnosis except CDI's....so just not sure.
    Deb

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

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    The queries you describe are leading and are not compliant. So, since any coder should know this is not a compliant practice and is not consistent with AHIMA advice, I would not code the condition and would elevate to my coding mgr for resolution.

    Bottom Line: Anyone noting a query in the chart should do so in compliant manner as the rules apply to all, not just CDS/Coding staff.

    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

  • annnd2009@gmail.comannnd2009@gmail.com
    edited April 2016

    From brief

    All professionals are encouraged

    to adhere to these compliant querying guidelines regardless of

    credential, role, title, or use of any technological tools involved

    in the query process.



    Thank you,

    Ann

    303-689-4793



    "Twenty years from now you will be more disappointed by the things that you
    didn't do than by the ones you did do. So throw off the bowlines. Sail away
    from the safe harbor. Catch the trade winds in your sails. Explore. Dream.
    Discover."* --Mark Twain *
  • jschoonhovenjschoonhoven
    edited April 2016
    I had 2 thoughts about this.


    1) Compliant or not, the providers are going to be feeling 'queried to death' I think. A CDS would in each of these cases be querying too, provided they were reviewing the case. It's not really beneficial to have an excess of communication.



    2) That said, if the CDI dept. cannot assure a near 100% review of cases, then we cannot blame the other depts. for coming up with a way to consistently get their message out regardless of our staffing issues and sick calls.


    Interesting topic to bring up!
    Janice

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

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    Does it? I should take a closer look. I absolutely agree that they are not compliant. I also am very uncomfortable with them. Its just strange because I actually have no control over them either...

    In their defense, they would not even know to look for these guidelines.

    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
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    Ahhh! Thank you!!!

    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

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    I think even in that case where all payers are not being reviewed, they could contact CDI with the patient info instead of placing the query themselves. Then CDI could make sure the documentation was not already in the record and place a query if needed. This is what we did with nutrition initially (we still do to a degree).

    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

  • jschoonhovenjschoonhoven
    edited April 2016
    Katy,
    I think that's a great idea. That's why I was really glad to see this topic brought up. Here, our RD's email us whenever they diagnose malnutrition. That helps the CDS select the case to do if it's within our review population.
    From this discussion it has belatedly occurred to me that we could take that a step further and add all those patients to our assignments. We created a process for doing this with all expired patients....I think we may find a similar benefit here as well.
    CDI Talk is great. Thanks everyone!

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

  • paxnerospaxneros
    edited April 2016
    Hey Katy!

    I'll chime in - I had asked Katy's opinion regarding our RDs querying physicians on Malnutrition & Obesity.

    I don't mind so much that they do so - but as all have said it needs to be compliant w/Query practice. I think the better solution would be let CDI do the querying - but - at least run the "query" through the CDI dept. For a "yay/nay".
    Not doing so has caused us to deal w/the ramifications and also cost our HIM Dept. The extra work of tagging them for deficiencies and/or faxing them to physicians to get the form completely filled out.

    I would have liked to have been in on the initial discussion at Forms Committee - because no one spoke up then - rather than be the one finding all the holes in the process on the back end. Someone from our Revenue Rec. Team (RAC Defenders!) Should have been there too.

    Norma T. Brunson, RHIA,CDIP,CCS,CCDS

  • vanessa.falkoffvanessa.falkoff
    edited April 2016
    We did have an issue with someone from another dept. placing a query and I sent them the hospital policies that state a query may be issued by CDI staff or by Coders. What does your policy say? :)

    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
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    Personally, I think the best solution is to leave the query function to a professional trained in all of the nuances of this complex task – is not that why we all advocate for our professional qualifications as a CDS? If you were ‘new’ to the profession of CDS and had no background or training in the field, and were tasked with issuing a query, would you be effective AND compliant?





    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

  • paxnerospaxneros
    edited April 2016
    We do not have a policy which addresses this situation.

    Paul - again I don't mind so much - RD's have the expertise in their areas - much like WOC. They are usually consulted for a patient evaluation before the account hits our list to review.

    I guess I look at it from the MDs POV - the RD - that I consulted - has said my patient meets clinical indicators for Malnutrition and is asking me if I agree. I think I would be more inclined to fill out their query than the person who is also asking me to specify HF.

    I just think the query should be (should have been in our case) proofed by CDI.

    Norma T. Brunson, RHIA,CDIP,CCS,CCDS

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    I agree, but I think when they develop this practice they are not thinking about it as a ‘query’ in the way CDI is. CDI’s are not making a dx and then asking a MD to confirm. We don’t actually see or interact with patients and making dx is not in our scope of practice. But the dietician and WCON’s are. They are assessing the patient and making a dx. Then they are sending it to the MD for confirmation.
    I am not arguing with you. I agree and think that CDI should retain this responsibility. I just see why they do not see it this way. They know nothing about a ‘compliant’ query. They have no idea how their dx may impact coding or reimbursement. They are just getting their dx validated and don’t identify the problems that we may see with this process.

    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

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    As far as I know, the only policies we have regarding queries are related to CDI's only. We don't have any hospital-wide query policy.

    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

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    Exactly....

    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

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    I was speaking in a more global aspect.

    If your RDs are ‘licensed and authorized to establish a diagnosis in your state”, why would they need to query? It comes down to the precise language per the State Agency overseeing the RD function in your state as well as your Medical Staff Bylaws?

    In California, a NP/PA is licensed and expected to ‘establish and document’ a diagnosis – accordingly, we may code directly from the notes of these providers. However, an RD is not authorized to establish independently a diagnosis, such as malnutrition, at our sites.

    So, if an RD is not able to establish a diagnosis, but subsequently offers a leading query to an MD, that would be an issue in my view. I would same the same for a Pharmacist, RN, Wound Care Nurse, and so forth.

    So, when you say the dietician and WCON’s are ‘making a diagnosis’, the scope of their official practice and licensure is a central 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

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    I see what you are saying Paul and I don’t feel that I have enough knowledge about legal scope of practice of these healthcare providers to take a firm stance. But I also would not take the coding guidelines that use only MD documentation to guide coding as evidence for why they do not make diagnoses. This is more of a payment issue in my opinion and says little about their scope of practice. Additionally, in the outpatient area many of these professionals to bill independently for their service.

    I do see the significant difference between nursing and these other specialties PT/WCON/Dietary, etc. Nurses do not make dx. This is explicitly stated in our training. In fact we are taught an entirely different system of making a ‘nursing diagnosis’ that does not involve a medical diagnosis (yes, its super annoying). Just on a functional level, nurses are do not carry their weight of assessing a patient, making a diagnosis, and determining treatment. This I not true for areas like WC or dietary. They work independently, often write their own orders, etc. They are considered the expert and do include real medical dx in their notes. Sure, coding regulations don’t allow us to pick it up unless the MD acknowledges it as significant but they do allow specificity to be pulled from their notes which I think speaks to the idea that these are truly the experts.

    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

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    Yes – the wound care nurses and the RDs are indeed experts within their realm of practice. Indeed, often the MD will rely upon these experts for guidance.

    However, my main point is that ‘if or when they do need to issue a query ‘ it must be compliant. It boils down to that central issue. It matters not the clinical expertise of the person issuing the query, it must be compliant.

    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

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    I agree. This is the advice I have provided. I think the struggle is that they don’t know anything about querying or even see it this way so they don’t know that there are guidelines associated with asking the MD to validate their dx. For instance, I just found out this week that ID has been ‘querying’ for CAUTI’s for a couple months. Eeeek!

    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

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    Indeed – perhaps you could help build a sample of compliant queries that would be pertinent and helpful for them ? Constructing a query seems ‘easy and intuitive’, but we all know how difficult it can be to compliantly and effectively issue 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

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    Yes, at minimum, this is the next step. Though, I think it may make more sense just to have them communicate directly with CDI so that we can place the query and follow-up with the MD to ensure a 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

  • mark.domineseymark.dominesey
    edited April 2016
    In this case I would wary of building queries for other departments. I know Paul you said ‘sample queries’ and that is probably safe as long as it is understood that the other department is responsible for their own content and for their queries being compliant. I certainly would not want to be on the hook for another department’s queries in case they turned out to be non-compliant!

    Mark



    Mark N. Dominesey, MBA, RN, CCDS, CDIP, CHTS-CP
    Director, Auditing & CDI Services
    Office: 202.489.4662
    Fax: 888.661.7790
    Mark.Dominesey@TrustHCS.com
    www.TrustHCS.com

    Read our blog: http://www.trusthcs.com/blog/

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    Katy: The thing to consider if you wish to place the query is the volume? Do you have the staff to intervene on all of these cases, place a query, f/u, etc?

    How many wound care evaluations and RD assessments do you average per day/week?

    Are U staffed to handle volume?

    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

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    Mark: I am assuming that a CDI department building a query would be capable of building one that is compliant – I also assume all CDI mgrs know any query is a part of the record and must be vetted and endorsed by Legal. In my view, these are basic query formulation practices.

    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

  • mark.domineseymark.dominesey
    edited April 2016
    Yep, no problem with that advice and statement at all.

    Mark



    Mark N. Dominesey, MBA, RN, CCDS, CDIP, CHTS-CP
    Director, Auditing & CDI Services
    Office: 202.489.4662
    Fax: 888.661.7790
    Mark.Dominesey@TrustHCS.com
    www.TrustHCS.com

    Read our blog: http://www.trusthcs.com/blog/

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    Yes. We have the staff.

    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

  • tkreilingtkreiling
    edited April 2016
    Just a thought—could the physician not just co-sign the RD assessment or the wound nurse assessment and indicate he agrees with assessment/diagnosis. That would eliminate the need for querying all together from anyone, though there is the constant need for chart review to make sure it is getting co-signed. We have a RD assessment that the RD fills out on our patients with a malnutrition dx and places in progress notes then the MD either agrees or disagrees. A list of who has a RD form placed on the chart prints daily. We have been asking our physicians to co-sign wound nurse photos/assessments of ulcers if they agree with the wound nurse’s assessment. Our physicians prefer that to querying.

    Tara, RN,CCDS

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    Yes. I also think this could work and have presented it as an option.

    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

  • paxnerospaxneros
  • tkreilingtkreiling
    edited April 2016
    Yes, our forms have the clinical indicators for each malnutrition type and they will circle the patients indicators which is under the specific type of malnutrition for the dx. They also document in the electronic record (our notes are still handwritten). The rest of our process sounds like yours, the doctors have the option to disagree and reason why. The coders will not accept the dx unless the form is completely filled out. We also fax or contact the physicians for completion (either agree or disagree) and the MR holds it as a deficiency until completed.
    Our IT set it up so when the RD documents that they placed a form on the record it will print a list to my printer the next day. To be honest, I rarely have to do much with these forms but do know our larger sister hospital does do a bit more chasing for completion.

    Tara, RN,CCDS

  • jlightfoot@marshallmedical.orgjlightfoot@marshallmedical.org
    edited April 2016
    We do the same thing with both nutrition and wound care assessments. Since coding guidelines are clear about who can document the staging of the staging of pressure ulcers we do not require additional documentation of the staging from our providers as long as they've documented that the pressure ulcer exists; however, we do ask them to continue documentation of any malnutrition diagnosis throughout the record.



    In short, we do NOT consider the physician agreeing and signing our dietician assessment ALONE adequate documentation.



    Does anyone have a coding guideline or coding clinic that specify otherwise?



    Also, our CDI team does all queries for quality issues (HACs/HAIs/surgical complications). Our work flow includes a process in which cases (all payors) having codes reflecting these conditions are referred for CDI review prior to bill drop; this does sometimes requires collaboration with infection control, wound care, coding and/or one on one discussions with physicians. We're very fortunate to have the staff to do this.



    Thank you,



    Jillian Lightfoot RN

    Clinical Documentation Team

    Marshall Medical Center

    Placerville, CA 95667

    (530) 626-2770 Ext. 6203

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