RE: [EXTERNAL] Question Regarding Criteria and Clinical Judgment
As long as the provider can document the justification for his clinical
decision then their decision stands. In the past when I've had these
issues I've had a provider to provider discussion between the insurance
company physician and our diagnosing physician. I've found that very
few physicians who haven't seen the patient are willing to override the
decision of the provider at the bedside.
And remember to, as CDI's we are not to question the providers clinical
decisions, just ask for documentation to better support those decisions.
Robert
Robert S. Hodges MSN, BSN, RN, CCDS, VHA-CM
Clinical Documentation Improvement Specialist
Secretary, Nursing Professional Standards Board
Aleda E. Lutz VA Medical Center
1500 Weiss Street, ATTN PAS-136
Saginaw MI 48602
989-497-2500 x13101
Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence
("I CARE")
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative,
Agile, Integrated
"The difference between the right word and the almost right word is the
difference between lightning and the lightning bug." Samuel "Mark Twain"
Clemens
decision then their decision stands. In the past when I've had these
issues I've had a provider to provider discussion between the insurance
company physician and our diagnosing physician. I've found that very
few physicians who haven't seen the patient are willing to override the
decision of the provider at the bedside.
And remember to, as CDI's we are not to question the providers clinical
decisions, just ask for documentation to better support those decisions.
Robert
Robert S. Hodges MSN, BSN, RN, CCDS, VHA-CM
Clinical Documentation Improvement Specialist
Secretary, Nursing Professional Standards Board
Aleda E. Lutz VA Medical Center
1500 Weiss Street, ATTN PAS-136
Saginaw MI 48602
989-497-2500 x13101
Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence
("I CARE")
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative,
Agile, Integrated
"The difference between the right word and the almost right word is the
difference between lightning and the lightning bug." Samuel "Mark Twain"
Clemens