"anti" query
I wonder if some may have input to thoughts of an "anti" query...i.e. dx of AKI / acute renal failure. Is it okay to say/ write on the query, that the lab values do not support or meet the criteria for coding acute renal failure? Sometimes I wonder if it is "leading" ? or just stating the facts ?. (especially when the documentation reflects that the creatinine level is related to dehydration) then they are asked for clarification.
How do others approach an "anti" query with physicians? Especially when it is well documented throughout the medical record.
The physician has the ability to answer AKI without failure, hemoconcentration of dehydration, azotemia, acute renal failure or other.
TGIF!!
Lona McNamara RN, BSN, CCM
CDIS, Cortland Regional Medical Center
lmcnamara@cortlandregional.org
How do others approach an "anti" query with physicians? Especially when it is well documented throughout the medical record.
The physician has the ability to answer AKI without failure, hemoconcentration of dehydration, azotemia, acute renal failure or other.
TGIF!!
Lona McNamara RN, BSN, CCM
CDIS, Cortland Regional Medical Center
lmcnamara@cortlandregional.org
Comments
I don't think it's leading. Below is a query I use for an "anti" query.
Your assistance with confirmation of a documented diagnosis is requested.
Diagnosis: ___________________is documented in the ________________. It doesn't appear from documentation that patient meets criteria for _______________.
Would you please confirm and provide any additional relevant information to further support the diagnosis in the patient medical record.
1. This diagnosis is not confirmed and/or has been ruled out.
2. This diagnosis is confirmed.
Please document your clinical rationale_____________________________.
Paula Scheiderich, RHIT
Clinical Documentation Specialist
Oneida Healthcare
315 363-6000 Ext. 1084
pscheiderich@oneidahealthcare.org
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, February 12, 2016 8:32 AM
To: Scheiderich, Paula
Subject: [cdi_talk] "anti" query
I wonder if some may have input to thoughts of an "anti" query...i.e. dx of AKI / acute renal failure. Is it okay to say/ write on the query, that the lab values do not support or meet the criteria for coding acute renal failure? Sometimes I wonder if it is "leading" ? or just stating the facts ?. (especially when the documentation reflects that the creatinine level is related to dehydration) then they are asked for clarification.
How do others approach an "anti" query with physicians? Especially when it is well documented throughout the medical record.
The physician has the ability to answer AKI without failure, hemoconcentration of dehydration, azotemia, acute renal failure or other.
TGIF!!
Lona McNamara RN, BSN, CCM
CDIS, Cortland Regional Medical Center
lmcnamara@cortlandregional.org
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
________________________________
The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is intended only for the use of the person(s) named above. If you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. If you are not the intended recipient, please contact the sender by reply email and destroy all copies of the original message.
At the last hospital I worked at, we called these reverse queries. We asked the physician to provide the clinical indicators in support of the listed diagnosis or the diagnosis in question. I think you just have to careful to not question the physician's judgment or say the diagnosis is not appropriate based on the clinical indicators. If the physician did not respond or did not provide the clinical indicators, the query was escalated to the physician advisor.
David Reece, BSN, RN, CCDS
Manager, Quality Documentation Services
Premier, Inc.
Cell: 336-480-7541
David_Reece@PremierInc.com
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, February 12, 2016 8:32 AM
To: Reece, David
Subject: [cdi_talk] "anti" query
I wonder if some may have input to thoughts of an "anti" query...i.e. dx of AKI / acute renal failure. Is it okay to say/ write on the query, that the lab values do not support or meet the criteria for coding acute renal failure? Sometimes I wonder if it is "leading" ? or just stating the facts ?. (especially when the documentation reflects that the creatinine level is related to dehydration) then they are asked for clarification.
How do others approach an "anti" query with physicians? Especially when it is well documented throughout the medical record.
The physician has the ability to answer AKI without failure, hemoconcentration of dehydration, azotemia, acute renal failure or other.
TGIF!!
Lona McNamara RN, BSN, CCM
CDIS, Cortland Regional Medical Center
lmcnamara@cortlandregional.org
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
So maybe you could establish criteria from one of you Neph providers and create a policy and query based on that and include that criteria ON your query?
Good luck!
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, February 12, 2016 6:32 AM
To: Bovard, Juli
Subject: [cdi_talk] "anti" query
I wonder if some may have input to thoughts of an "anti" query...i.e. dx of AKI / acute renal failure. Is it okay to say/ write on the query, that the lab values do not support or meet the criteria for coding acute renal failure? Sometimes I wonder if it is "leading" ? or just stating the facts ?. (especially when the documentation reflects that the creatinine level is related to dehydration) then they are asked for clarification.
How do others approach an "anti" query with physicians? Especially when it is well documented throughout the medical record.
The physician has the ability to answer AKI without failure, hemoconcentration of dehydration, azotemia, acute renal failure or other.
TGIF!!
Lona McNamara RN, BSN, CCM
CDIS, Cortland Regional Medical Center
lmcnamara@cortlandregional.org
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
----------------------------------------------------------------------
Regional Health is an integrated health care system with the purpose of helping patients and communities live well.
Note: The information contained in this message, including any attachments, may be privileged, confidential, or protected from disclosure under state or federal laws . If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the Sender immediately by a "reply to sender only" message and destroy all electronic or paper copies of the communication, including any attachments.
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, February 12, 2016 8:52 AM
To: McNamara,Lona A
Subject: RE:[cdi_talk] "anti" query
Hi Lona,
At the last hospital I worked at, we called these reverse queries. We asked the physician to provide the clinical indicators in support of the listed diagnosis or the diagnosis in question. I think you just have to careful to not question the physician's judgment or say the diagnosis is not appropriate based on the clinical indicators. If the physician did not respond or did not provide the clinical indicators, the query was escalated to the physician advisor.
David Reece, BSN, RN, CCDS
Manager, Quality Documentation Services
Premier, Inc.
Cell: 336-480-7541
David_Reece@PremierInc.com
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, February 12, 2016 8:32 AM
To: Reece, David
Subject: [cdi_talk] "anti" query
I wonder if some may have input to thoughts of an "anti" query...i.e. dx of AKI / acute renal failure. Is it okay to say/ write on the query, that the lab values do not support or meet the criteria for coding acute renal failure? Sometimes I wonder if it is "leading" ? or just stating the facts ?. (especially when the documentation reflects that the creatinine level is related to dehydration) then they are asked for clarification.
How do others approach an "anti" query with physicians? Especially when it is well documented throughout the medical record.
The physician has the ability to answer AKI without failure, hemoconcentration of dehydration, azotemia, acute renal failure or other.
TGIF!!
Lona McNamara RN, BSN, CCM
CDIS, Cortland Regional Medical Center
lmcnamara@cortlandregional.org
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: david_reece@premierinc.com
If you would like to be removed from CDI Talk, please send a blank email to
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
---
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, February 12, 2016 9:10 AM
To: McNamara,Lona A
Subject: RE:[cdi_talk] "anti" query
For our ANTI-queries, we have established within our organization, certain RECOGNIZED criteria for diagnoses-like respiratory failure. We established the criteria with one of our Pulm specialists, and actually have that criteria ON the query. When we query, we ask; "please clarify your supporting clinical indicators from the recognized criteria below", or If using alternate criteria, request they document/ clarify that as well.
So maybe you could establish criteria from one of you Neph providers and create a policy and query based on that and include that criteria ON your query?
Good luck!
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, February 12, 2016 6:32 AM
To: Bovard, Juli
Subject: [cdi_talk] "anti" query
I wonder if some may have input to thoughts of an "anti" query...i.e. dx of AKI / acute renal failure. Is it okay to say/ write on the query, that the lab values do not support or meet the criteria for coding acute renal failure? Sometimes I wonder if it is "leading" ? or just stating the facts ?. (especially when the documentation reflects that the creatinine level is related to dehydration) then they are asked for clarification.
How do others approach an "anti" query with physicians? Especially when it is well documented throughout the medical record.
The physician has the ability to answer AKI without failure, hemoconcentration of dehydration, azotemia, acute renal failure or other.
TGIF!!
Lona McNamara RN, BSN, CCM
CDIS, Cortland Regional Medical Center
lmcnamara@cortlandregional.org
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: jbovard@regionalhealth.com
If you would like to be removed from CDI Talk, please send a blank email to
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
________________________________
Regional Health is an integrated health care system with the purpose of helping patients and communities live well.
Note: The information contained in this message, including any attachments, may be privileged, confidential, or protected from disclosure under state or federal laws . If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the Sender immediately by a "reply to sender only" message and destroy all electronic or paper copies of the communication, including any attachments.
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: lmcnamara@cortlandregional.org
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, February 12, 2016 8:50 AM
To: McNamara,Lona A
Subject: RE:[cdi_talk] "anti" query
Hi Lona,
I don't think it's leading. Below is a query I use for an "anti" query.
Your assistance with confirmation of a documented diagnosis is requested.
Diagnosis: ___________________is documented in the ________________. It doesn't appear from documentation that patient meets criteria for _______________.
Would you please confirm and provide any additional relevant information to further support the diagnosis in the patient medical record.
1. This diagnosis is not confirmed and/or has been ruled out.
2. This diagnosis is confirmed.
Please document your clinical rationale_____________________________.
Paula Scheiderich, RHIT
Clinical Documentation Specialist
Oneida Healthcare
315 363-6000 Ext. 1084
pscheiderich@oneidahealthcare.org
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, February 12, 2016 8:32 AM
To: Scheiderich, Paula
Subject: [cdi_talk] "anti" query
I wonder if some may have input to thoughts of an "anti" query...i.e. dx of AKI / acute renal failure. Is it okay to say/ write on the query, that the lab values do not support or meet the criteria for coding acute renal failure? Sometimes I wonder if it is "leading" ? or just stating the facts ?. (especially when the documentation reflects that the creatinine level is related to dehydration) then they are asked for clarification.
How do others approach an "anti" query with physicians? Especially when it is well documented throughout the medical record.
The physician has the ability to answer AKI without failure, hemoconcentration of dehydration, azotemia, acute renal failure or other.
TGIF!!
Lona McNamara RN, BSN, CCM
CDIS, Cortland Regional Medical Center
lmcnamara@cortlandregional.org
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: pscheiderich@oneidahealthcare.org
If you would like to be removed from CDI Talk, please send a blank email to
leave-cdi_talk-20310833.259494049ecb2fb97dab0594bf7e7398@hcprotalk.com
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
________________________________
The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is intended only for the use of the person(s) named above. If you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. If you are not the intended recipient, please contact the sender by reply email and destroy all copies of the original message.
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: lmcnamara@cortlandregional.org
If you would like to be removed from CDI Talk, please send a blank email to
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
Thanks for all the great sharing lately and have a Happy V Day!
Vanessa Falkoff RN
Clinical Documentation Improvement Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
Compassion * Accountability * Respect * Integrity
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, February 12, 2016 6:10 AM
To: Vanessa Falkoff
Subject: RE:[cdi_talk] "anti" query
For our ANTI-queries, we have established within our organization, certain RECOGNIZED criteria for diagnoses-like respiratory failure. We established the criteria with one of our Pulm specialists, and actually have that criteria ON the query. When we query, we ask; "please clarify your supporting clinical indicators from the recognized criteria below", or If using alternate criteria, request they document/ clarify that as well.
So maybe you could establish criteria from one of you Neph providers and create a policy and query based on that and include that criteria ON your query?
Good luck!
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, February 12, 2016 6:32 AM
To: Bovard, Juli
Subject: [cdi_talk] "anti" query
I wonder if some may have input to thoughts of an "anti" query...i.e. dx of AKI / acute renal failure. Is it okay to say/ write on the query, that the lab values do not support or meet the criteria for coding acute renal failure? Sometimes I wonder if it is "leading" ? or just stating the facts ?. (especially when the documentation reflects that the creatinine level is related to dehydration) then they are asked for clarification.
How do others approach an "anti" query with physicians? Especially when it is well documented throughout the medical record.
The physician has the ability to answer AKI without failure, hemoconcentration of dehydration, azotemia, acute renal failure or other.
TGIF!!
Lona McNamara RN, BSN, CCM
CDIS, Cortland Regional Medical Center
lmcnamara@cortlandregional.org