Diagnosis without clinical indicators
CDI's role in Diagnosis without clinical indicators.
Recently we have seen an increase in the documentation of sepsis with little to no clinical indicators. I have a query that ask for supporting clinical indicators but what do you do when there are NO clinical indicators to support the diagnosis?
Thanks,
Dorie Douthit
ddouthit@stmaryshealthcare.org
Recently we have seen an increase in the documentation of sepsis with little to no clinical indicators. I have a query that ask for supporting clinical indicators but what do you do when there are NO clinical indicators to support the diagnosis?
Thanks,
Dorie Douthit
ddouthit@stmaryshealthcare.org
Comments
Janice Schoonhoven RN, MSN, CCDS
Clinical Documentation Integrity
Manager- PeaceHealth Oregon West Network
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 do here what I call a 'reverse query' and ask whether Sepsis was ruled out (as first option, 1st line) followed by options for resolved or 'other'
Then we list the clinical indicators--SIRS indicators basically, that do not show as issues. Example - Temp 36.9, HR 54, BP 126/88, WBC 6.6, neut% 68
This gives the physician a chance to 'rule out' the diagnosis that should not have been written to begin with.
I find this pretty easy to do with Sepsis since it has clear criteria. I find it much trickier with a diagnosis like Acute respiratory failure when it seems to be inappropriately documented.
One-on-one hallway discussions are our preferred method for these less cut and dry situations, and also for clarifying PSI's and complications...
Janice
Janice Schoonhoven RN, MSN, CCDS
Clinical Documentation Integrity
Manager- PeaceHealth Oregon West Network
You ask; "what supporting indicators were used to support that diagnosis-based on the recognized standard criteria of; (then list them)" OR to clarify what criteria were used if not the recognized criteria". We OFTEN query for lack or NO indicators, and have been encouraged to do just that from our consulting group!
IT is precisely why we would query if they don’t have or meet criteria for say sepsis, or resp failure. MANY times once we query the provider will give us indicators THEY used that aren’t normal criteria OR answer ruled out after study (which is a choice on our queries). RAC/Humana will come in and look at that chart with no indicators and disagree with a diagnosis. AGAIN, a provider can use any indicators he wants, but we query DAILY on this issue and about 50% of the time the provider will say ruled out-which goes to show a query was warranted. In the other 50% they use indicators like Lactic acidosis and hypotension. In any case, I say query away!
Juli
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 do follow up with one of the hallway at-chart discussions about how they could support this diagnosis better in the chart.... mentioning the non-medical auditor that will be reviewing this from afar down the road.... how can we be sure this is clear?
We have had very good results in this process.
Janice
Janice Schoonhoven RN, MSN, CCDS
Clinical Documentation Integrity
Manager- PeaceHealth Oregon West Network
541-222-5348
To me, even if he tells me it is resolved, I still am not able to determine what criteria he used which worries me. Our coders would still wonder what criteria was used to support the diagnosis. We educate our providers to DOCUMENT what indicators they use for diagnosis but they don’t always do it.
I guess the bottom line is, if a layman comes in 2 years from now and were to look at a chart, I would want them to know what indicators (any) were used to support a diagnosis.
Just my opinion!
Juli
1. Confirm above diagnosis (Please state clinical indicators)
2. Diagnosis was ruled out (please state more appropriate diagnosis if applicable).
3. Other
4. Unable to determine
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
Syndi Hudson, RN, CCM
CDI Specialist
Christus Santa Rosa New Braunfels
600 North Union
New Braunfels, Texas 78130
cynthia.hudson@christushealth.org
830-643-6116 (Office)
830-643-5139 (Fax)
"I press on toward the goal to win the prize for which God has called me." Philippians 3:14
Deb
1. confirm dx by stating CI (the must state)
2. r/o dx (or replace)
3. Other
4. Unable to determine
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
Curious, what is the source for your clinical criteria?
Are these formally adopted by your medical staff for organizational dx definitions?
Certain dx's have widely accepted literature definitions (sepsis, AKI, MI for example), many other dx's have varying degrees of accepted literature support. These later I feel especially benefit from organizationally agreed to definitions -- strongly helps with future auditing defense also.
To the original message and many responses, I fully agree with the need to query. Just be careful that you are looking for ALL of the criteria as described in the surviving sepsis campaign article prior to query.
I like the options of ruled out, ruled in/remained possible (with request for clinical support), etc.
This is one of the critical roles for CDI that has developed in the past several years -- seeking full accuracy of the dx record (specifically removal of copy/paste, vague clinical support, etc.)
Don
An example is provided in the acutl document, and I believe we can all access this document from the ACDIS Web Site.
A lot of hard work I suspect, but this I see that as best practice that we should all consider emulating (definitions of diagnosis driven by medical staff).
Thanks, you demonstrate (and share) repeatedly a real level of excellence.
Don
Deb