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

Comments

  • edited May 2016
    You don't query.

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


  • I think the idea is (and this may require physician education), that the physician is responsible for supporting their dx with CI's. If they have no CI's to support the dx, they should be responding with a more appropriate 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

  • edited May 2016
    Sorry, that was too simple!
    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


  • I disagree with no query- I say this is when a query is warranted!


    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

  • And if they respond with 'rule-in'??

    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


  • edited May 2016
    The option is 'resolved' which at least is a clear-cut response that will not have to be re-queried by the coders after discharge.
    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


  • Though we cannot determine if an auditor WILL review a chart, I still query knowing we need QUALITY documentation for these diagnosis that aren’t showing clear cut indicators. Again, it is the providers judgment (as he is laying eyes on the patient) for indicators used to support a diagnosis, but for a DRG / PDX like sepsis, I want to know WHAT indicators they are using to support this diagnosis if they aren’t the standardized criteria. That is why if they tell me they uses Lactic acidosis and Hypotension then I am DONE. I asked, they told me and that is that.

    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

  • This is my standpoint too. Saying 'resolved' does not seem to address the issue that there are not clear clinical indicators in the record. Many times the provider may have clinical criteria they are using that have not been tied to the diagnosis. This is why I think it is beneficial to ask them to supply the clinical indicators if they want to maintain the dx. Our options are as follows:
    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


  • Our quality department reviews all sepsis charts for clinical indicators prior to final coding. Physicians are queried about cases that do not meet clinical indicator guidelines.

    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







  • Our CDI put the Sepsis or Acute respiratory failure quidelines query on a chart like this and ask was sepsis/or acute resp.failure ruled out, this gives them the option AGAIN to see the criteria and make the best informed decision, and they can also see where they jumped-the-gun (so to speak) with the inappropriate diagnosis, and where they did not make sure the patient met ALL criteria or enough of the criteria to support that diagnosis. Almost ALL the time our providers will correct this documentation by just saying Sepsis ruled out after further study, etc.

    Deb


  • Great point Deb. We have actually just recently done this too for sepsis, resp failure, renal failure, and encephalopathy for Clinical Indicator queries. So we have the diagnostic criteria listed, then the patient picture is described and then the provider can respond with
    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


  • Katy:
    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

  • This situation is addressed in the February 2013 Combined Query Best Practice issued jointly by AHIMA/ACDIS. (Bullet #4)

    An example is provided in the acutl document, and I believe we can all access this document from the ACDIS Web Site.

  • Outstanding!!
    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

  • Our Medical advisor also drives and agrees on the criteria we use to determine many of our diagnosis...specifically for Sepsis/sirs w/infection, acute renal failure, acute resp. failure etc. Our CDI program put together most of our query forms but they were approved by the medical staff and specialty physicians...cardiology, renal, etc.

    Deb

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