Decubitus

Hi all,

In your opinion is it appropriate to simply query for significance on a diagnosis made by a non-physician?

For example: Currently if we have a diagnosis that is in a Rad report or something similar but a treating provider has not documented it, we place a 'non-treating provider' query that basically asks if the attending agrees with the dx as being medically significant.

Could the same type of query be used for situations like a pressure ulcer that is identified by a WCON? We currently have a different query that we use for this but it feels so much less direct. I would prefer to simply ask if the provider agrees with the dx.

I am NOT referring to dx made by someone not 'legally responsible for establishing a diagnosis' as the coding guidelines phrase it. I am specifically referring to diagnoses made by a specially trained care team member (nutrition/WCON/PT/etc).

Thoughts?

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

  • edited May 2016
    I would place a query stating that wcon documented findings of the ulcer. If they concur with these findings please document in progress notes.

  • Agreed -- the accepted concept for review of a record to establish the
    coding data set is to review ALL of the documents.
    In the case of the wound care nurse, as well as nutritionist, these are
    the experts that medical staff often turn to for assistance with their
    area of expertise.

    Don

  • We have a potential to query the physician in two fashions:

    1. We have a present on admission query if the information is not mentioned in the admitting history and physical.

    2. We also query to see if the physician agrees with the information. We clearly identify where the information has been found and quote the person/report where we obtained the information. This is extremely helpful especially in terms of wound care. Our wound care nurses might identify a pressure ulcer to the ischium and the physician may identify a pressure ulcer to the back/sacrum. This allows us the opportunity to query for specificity in location and stage.

    Lisa Romanello, RN,BSN,FNS,CCDS
    Manager, Clinical Documentation Improvement
    Quality and Compliance
    CJW Medical Center
    Office phone: 804-228-6527
    Cell phone: 804-629-0396
    AHIMA Approved ICD-10 CM/PCS Trainer
    Angelisa.Romanello@HCAHealthcare.com




  • Agree: Include Pathology Reports, pertinent Radiology Studies, and evaluations by RN, Wound Care Team, RD, PT, etc.

    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:  415.412.9421

    evanspx@sutterhealth.org



  • So now I have coder questioning if this type of query is acceptable….For those of you who said it is acceptable to ask an MD to confirm or deny a dx made by wound care/nutrition, how would you defend it?

    We basically just set up the query to state:

    Wound Care RN has documented a stage 2 decubitus in their note on 10/31. Do you concur with these findings identified by the WCON and find the diagnosis listed as medically significant in the care/treatment/monitoring of this patient?

    Yes, I agree that this is a medically significant diagnosis
    No, I do not agree
    Other
    Unable to determine.

    Of course I went to the Practice Brief and I am not sure where this lies. They say:

    "Yes/no quereis may not be used in circumstances where only clinical indicators of a condition are present and the condition/diagnosis has yet to be documented in the health record. Also new diagnoses cannot be derived from a yes/no query"

    Also... they say a Yes/no query is approrpiate when
    "substantiating or further specifiying a diagnoses that is already present int he health record (i.e., findings in apathology, radiology, and other dignostic reports) with interpretation by a physician"

    These are not documented by a physician but by another staff memeber who is accountable for the diagnosis.

    thoughts?

    thnak 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
  • I may have missed part of this, but did the provider document the decubitus at all? If he did, you can take the stage from the WCT notes. I would wonder who put in the consult for WCT to begin with-or was it nursing directed through an assessment? If you ask him the question below (depending on the admit date), you may want to add if it was POA?

    Juli

  • I think the orders are autogenerated when nursing documents a pressure ulcer. For nutrition, they are autogenerated with a low Braden or ordered by the MD.

    Good point on POA.

    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 would consider listing the diagnosis in the choices, not just yes I agree.

    I.e. Yes I agree with Severe protein Calorie malnutrition

    Or just list her answer amongst choices

    Severe protein calorie malnutrtion
    Moderate..
    and on and on

    Ann



  • So sorry!! My brain is done! It registered as malnutriton to me--UGHHHHH!!! So Sorry!

    But I still might list the site and fact that it's a pressure ulcer in choices.


    Ann
  • No problem. I am talking about both dx anyways. Malnutrition and pressure ulcers.
    To clarify, we have been querying on these diagnoses forever based on nutrition/WCON documentation. The current discussion is surrounding whether it is appropriate to query asking the provider whether they agree with the dx made by that care team member rather than basically presenting the clinical indicators and an exerpt from the nutrition/WCON note stating the dx and then asking them what is being treated (providing options).

    Thanks again for all your help.

    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
    That is the way I had done it for years too, but listened to an audio from ACDIS earlier this year that stated it was not compliant to ask if they concur with wound nurse. I will see if I can find the audioconference name and can email you it.

    Also, just as a FYI- I was taking the wound nurse documentation of a pressure ulcer on admit to assume we could assign POA of yes. There is a POA question in the back of the DRG book that addresses that very question and says we cannot take nursing assessment for the POA status. So I have to change my way of querying all together.
    Tara, RN, CCDS.


Sign In or Register to comment.