Question Regarding Criteria and Clinical Judgment

First let me say that I realize review organizations and external audits by payers have greatly changed or influenced the manner in which medical care is provided. No need to reiterate that but my question is this:

What if a physician still feels a patient has sepsis or respiratory failure or encephalopathy or ? even though the established criteria is not met? Are they allowed to make that determination based their clinical impression of an individual's presentation? Or must all patients fit neatly into the box for that diagnosis?

I keep thinking of what one of the presenter's at this year's conference said when he paraphrased Chief Justice Stewart and said "Sepsis is a lot like porn. I can't give you a definition but I know it when I see it."

I feel like the tail is wagging the dog sometimes. I don't have a solution and am wondering how others feel about this. What do you do when this occurs? Do physicians even need to see the patient? Can we just check boxes based on clinical findings, test results, etc. and ask the MD's to agree or disagree? I know we say we are not questioning their clinical judgment but we really are, aren't we?

I am just throwing this out to you all to get your take on this. (Don't hate the question asker!)

Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org

Comments

  • I see it like this:
    The provider can make whatever diagnosis they see fit with whatever criteria they are using. That being said, the insurer may not always agree and may not pay for the care provided. I don't think this should change how physicians make their diagnoses but it should make them think about how they would defend it (what is the diagnostic criteria they are using and is it supported in medical literature?). We will not always win every single one of these battles....

    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

  • This is issue impacts how data for all providers is reported and has profound implications for all of us...personally, I would like to ask members of our Board to provide insight during the next Quarterly ACDIS Conference Call.

    I have worked denials whereby RNs working for insurance companies and the RAC refuse to acknowledge codes assigned appropriately for conditions such as acute kidney and acute MI (partial list) charted by treating physicians very clearly and meeting commonly accepted evidence-based (and consensus-base) definitions universally accepted in the Medical Community.



    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

  • edited April 2016
    I agree with Paul about the insurers denying based on their own criteria that aren't always in alignment with current clinical and coding standards. I'm tired of telling them that they can't deny pneumonia because the patient doesn't have jugular vein distention.

    I think that over the years we've done, for the most part, a pretty good job of teaching physicians to attach high-profile, high acuity diagnoses to their charts, and now we have to step back and teach them to attach clinical indicators that are appropriate for those diagnoses. I use a graphic that shows the ideal record with clinical indicators, documented diagnoses, and treatment plan all in alignment. What helps is if the medical staff establishes evidence-based criteria in conjunction with diagnoses that all of the medical staff is expected to follow, and then the query can simply measure the documentation against the recognized standard. Sepsis often really is, though, one of those diagnoses that you "know it when you see it." It's one of the reasons I'm actually glad that "SIRS due to infection" is no longer going to be synonymous with sepsis when the record is coded. It's why we need a strong clinical background, wherever derived, when reviewing records. It's why we need a strong escalation policy to take these questions to a physician advisor who can have that doc to doc discussion. It's why we have these interesting discussions on CDI Talk, and I, for one, do not "hate the question asker," Sharon, but am glad you asked.

    Just my $0.02.

    Renee

    Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
    Director, Clinical Documentation
    Tanner Health System
  • edited April 2016
    Renee, Would you mind sharing the graphics you use for the 'ideal record'? Thank you in advance.

    Debbie dwhite@tfhd.com

  • edited April 2016
    Thank you for asking the question. I appreciate you. Mary


  • edited April 2016
    Sharon -- I am so glad you brought this issue up. I think most people don't want to talk about this very sensitive issue. I also think your concerns are more prevalent then we think or hear about. It takes courage to speak up. According to both ACDIS and AHIMA's Code of Ethics and ethical standards we need to take your question and concerns seriously. Like Paul proposed both ACDIS and AHIMA needs to do more about bringing this to the forefront and start talking about it more. Adherence to these standards assures public confidence in the integrity and service for all healthcare members.

    As unpopular as this might be, I feel that the payors are reacting to overuse of certain conditions that yield a higher DRG payment and are now out of control by denying everything.
    I have seen Sepsis diagnosed for almost every admission. I've seen Acute Respiratory Failure diagnosed for every patient that has COPD exacerbation with treatment no different than the standard protocol for treating a COPD exac. on 2L of O2. I've seen encephalopathy in demented patient's that showed some confusion for a short period of time. As a coder, it is easy to see a pattern when this is occurring. I do feel there are hospitals that target the certain conditions and have taught the hospitalists to document this way when they don't show the clinical validity in the documentation.

    Of course, there are many hospital facilities that would not allow that but there are hospitals that do which has caused payors to react and take advantage by denying when they shouldn't. It is definitely a vicious circle we are dealing with.

    I believe that we should not ever question a physician's clinical medical decision-making but we are obligated to question the documentation in the record to ensure documentation integrity and clinical validity.

    Over the years, CDI has done an exceptional good job training physicians but somewhere along the way, the physicians are trying to do what they have been taught maybe to avoid a query but they are not providing the reasoning why they are diagnosing these conditions, especially on these 1-2 day stays. I don't blame the payors for denying a DRG with a single CC/MCC. We should all be concerned about our Social Security.

    We need to stop those physicians and/or facilities that are doing this and get them re-trained. We need to get back to the basics and ask the physician's to support their diagnoses with clear medical rationale and reasoning not based on a point system.

    Coding Management that won't allow coders to query for clinical validation in these type of situations because they say if the physician documents it, just code it and let the back end deal with it. Compliance Auditors saying we know 90% of these patients don't have Sepsis but we have to follow Coding Guidelines that tell us to code Septicemia as Principal.

    Everybody knows the problems but apparently don't want to go back and tell the physician that sometimes 2 SIRS criteria with infection doesn't mean the patient has Sepsis. Not every patient with COPD exac. has Acute Hypoxic Respiratory Failure and not every patient that seems a little confused has encephalopathy. Not every patient that is dehydrated has AKI.

    I applaud all those facilities and CDI programs that have worked hard to not focus on reimbursement only and do the right thing by sticking to what Clinical Documentation Improvement should be all about.

    And that's all I got to say about that.

    Debra Beisel Denton, BBL, RHIA, CCS, CCDS
  • Hi, Debra

    You make valid points; I, too, have reviewed cases whereby 'every' patient w/ COPD is stated to have 'acute respiratory failure', yet the clinical criteria does not support the documentation. In my practice, this is the exception rather than the rule. In such situations, we are compelled to follow AHIMA/ACDIS Best Practice, as per bullet point below:



    The generation of a query should be considered when the health record documentation:

    •Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
    •Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis
    •Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure
    •Provides a diagnosis without underlying clinical validation
    •Is unclear for present on admission indicator assignment

    I think the goal of CDI and Coding Practice is to have the documentation and subsequent coding accurately reflect the clinical condition for every encounter.

    Where I DO take issue is when a 3rd party will DENY coding of conditions that DO meet accepted clinical criteria and ARE also clearly documented, and also the 3rd party will simply state something like....'does not meet criteria for the condition' without any further justification or citation of pertinent criteria.

    In my view, this unacceptable. I do believe that 'all of us' should vigorously oppose those denials that do not cite clear rationale for the denial.

    On a related note, some of the 3rd parties will often lack an understanding of the rules of reporting and coding that must be followed per HIPAA. In order to deny a claim, a 3rd party must be able to cite clear rationale and evidence for the denial.


    Thanks, PE


    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



  • I am so glad that someone asked the question that we are all thinking ourselves. Some very good points made and I appreciate the fact that we all seem to be fighting the same battle. We actually had an auditor advise us to include verbage in our contracts with each provider that we and THEY would follow the SAME Official Coding Guidelines, Coding Clinic Advice, AHIMA Query Practice Brief, etc and that denials usually decreased if this verbage is also used in our appeal letters. We are in the process of this so I can't attest if this is going to help or not but it's worth a try at this point. And....Amen on the dreaded "jugular vein distention".

    Thanks everyone for sharing!

    April Herod Floyd, RN, CCDS
    Anderson Regional Health System
  • Hi Paul,

    Absolutely agree that is what we should do, but my frustration comes from facilities that don't want to follow Best Practices or just don't feel they can. Best Practices is what we all should aspire for but in the real world of coding and with the pressures of getting the bills out the door and productivity issues, coders are told not to query, not to question clinical validity. Told they are not qualified to question a physiciansdiagnosis. Unfortunately, some coders have taken the attitude it is NOT their job to question the documentation even when they know a diagnosis isn't supported or even when our Coding Guidelines tell us we should. They say if the CDI didn't get it clarified, it is NOT my problem and just code whatever is documented in fear of retaliation by management. It is a sticky situation, because if they don't question it and just code whatever even when it doesn't make any clinically sense most likely it will get denied. Even when clinical evidence and indicators are supported the payors are still denying. The coders who are the last person to see the documentation before it goes out the door should be trying to get the clinical picture accurately reported but told not to hold accounts. Please understand I am not trying to be Debbie Downer here, but sharing the reality of what I am seeing out there in the past several years. That is why CMS and other payors are clamping down so hard because they see it all too well. It comes from the top down and if the CDI and coder aren't allowed to work together to make sure Best Practices are followed than we remain in this vicious circle of denials. We must stand by our Code of Ethics and Standards with integrity as they are the measuring stick. Coding Managers are pressing down hard for the coder to meet her productivity quoto and if querying is going to take too much time they opt out and make the excuse that the CDI should not done it. Querying is discouraged in some facilities and the coders are being told let them worry about it on the back-end. Everyone is working in their own silo passing down the problem. I know you said you think that is an exception to the rule. I wish I could agree. I have worked in many hospitals as a traveling CDI and Coder and it is happening more and more than I care to admit and that is why I am so concerned. I think both the ACDIS and AHIMA need to step up more and address this issue more than they have and ask people to stop putting their heads in the sand. Let us all be courageous and speak up when we know this is happening. I know how hard it is if you feel your job could be on the line, I've been there. But the more people that will stand up to ask for change, then this vicious circle might stop and maybe then the payors would be more willing to stop denying everything using their own criteria. We must continue to fight every case that a reviewer denies by interpreting the guidelines wrongly or for trivial reasons and we must challenge those physicians who are documenting poorly and without the clinical indicators and evidence to support it. Then maybe things will change and get better.
  • I agree w/ your thoughts. I have left a few jobs that stressed coding production at the expense of quality. Many in the industry are far too concerned w/ production, at the expense of quality.

    Also contributing the problem is the poor pay afforded by the industry to educated, qualified, credentialed coders.

    PE

    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



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