Query using previous record
I know in some scenarios we can use information from previous admissions to use in a current query - historical labs to stage a documented CKD, previous echo result to clarify a history of CHF, etc. I came across a retrospective coder query in one of our records that I am not sure about. This patient was admitted with an iatrogenic pneumothorax from a lung biopsy done a few days ago. The biopsy was done at our facility and so the results are in our system. The biopsy results show adenocarcinoma of the lung. The coder issued a query asking if the physician agrees with the biopsy findings, in hopes of adding a CC in the form of the adenocarcinoma. Even though the lung biopsy was mentioned this admission, if was only mentioned as being the cause of this iatrogenic pneumothorax. Any thoughts on the compliance of this query?
Angelique Daigle RN, BSN, CCDS
CDI Lead @ St. Joseph Mercy Oakland
Pontiac, MI
Comments
If I were to be asked to write a query for this, I believe I would have asked why the biopsy that caused the iatrogenic PTX was done in the first place in the hopes that the doc would then mention the adenocarcinoma. I would not have asked for the results of a biopsy done on a prior admission outright like this...
Perhaps someone can find a pertinent coding clinic or something that directly references these types of situations. Interesting!
Amy Stremming, RN, CCDS
Clinical Documentation Nurse Auditor @ Vanderbilt Medical Center
Nashville, TN
My question with the current example is does it meet the UHDDS criteria for a reportable secondary diagnosis? I would be more inclined to ask if there was treatment directed specifically at the adenocarcinoma (consult, etc). I would not ask otherwise.
Jackie Touch, MSN, RN, CCM
CHOC Children's
"My question with the current example is does it meet the UHDDS criteria for a reportable secondary diagnosis? I would be more inclined to ask if there was treatment directed specifically at the adenocarcinoma (consult, etc). I would not ask otherwise.
Jackie Touch, MSN, RN, CCM
CHOC Children's "
We may query an MD to ask about the 'clinical significance' (confirm findings) of a pathology report if/when it documents an important condition that impacts risk factors, mortality, so forth. With that in mind, I think a cancer of the lung is 'always' reportable, (unless eradicated) same as other major conditions with impact to affect pt, such as diabetes, morbid obesity, COPD, Cardiomyopathy.
Paul Evans, RHIA, CCDS, CCS, CCS-P
"There is a whitepaper on this topic in the resource library ("Physician Queries and the Use of Prior Information"). I have used information from outpatient visits, previous hospitalizations, etc. to clarify for a current encounter only if the indicators, risk factors and treatment for that condition are present during the current stay and meet UHDDS criteria as a reportable diagnosis"
I looked at the white paper and it does not address ( or I missed it) the use of information in outpatient visits, previous hospitalizations, etc., to use in a query. It is from 2013. The 2016 compliant query statement stated "clinical indicators" should be from this historical encounter.
Things change so often. I know the echos were used by quality/Core Measures for CHF type- and it had been acceptable, a few years ago.
This isn't something I am seeing consistency across facilities. Does your facility disallow past lab work, echocardiograms, historical weights, etc to be in a clinical indicator in a query? Whether the intent or not that is what the position paper states, "clinical indicators should be derived from the specific medical record under review and the unique episode of care" ... but it also says "the intent of this brief is not to limit clinical communication for purposes of patient care but rather to maintain the integrity of the coded healthcare data".
I am not talking about CODING from the previous record but showing patient trends. Showing a change in a creatinine, weight or radiographic result, etc, for the purpose of showing an accurate patient picture.
Thanks for any input!