Mortality reviews when to query for dying patients
Our community hospital has started to review mortalities. We continue to find conflicting opinions regarding if it is ok to query during the dying process to enhance SOI/ ROM. When is it appropriate to place a query? When a patient is actively dying or only up until they are placed on hospice. I have been unable to find an official statement/ coding clinic…
UHC notes in a May 2012 webinar Mining the metrics of risk models, “when a patient is a DNR or on palliative care and they die; look for associated conditions of the dying process and query physician to document. Do not miss out on documentation and coding of CC’s and MCC diagnosis of the dying process.” In a march 19 2009 CDI tip, “look for documentation opportunities in DNR patients, it notes “Ask the physician to document the dying process… many of these conditions are likely opportunities for a query. In an April 2013 article from HCpro, “How to overcome physician resistance to providing complete and accurate documentation for the dying patient” La Chaite writes, “I do not condone querying for a diagnosis that would be considered part of the dying process. For example, querying for acute respiratory failure or acute encephalopathy for a patient who has been transitioned to comfort care measures, including a narcotic drip for pain control would be unnecessary. If this diagnosis did not exist prior to the institution of that drip….” CDI talk has previously brushed on the topic. Most seem to query up until the point of a comfort care or DNR order but not after that. Please advise, we want to use best practice.
Thanks Cyndy
Comments
If a patient has been made comfort care and is on a morphine gtt, it would not be appropriate to query for the underlying etiology of decreased o2 sats or AMS as these are expecting findings and integral to comfort care. However, if a pt had episodes of AMS due to infection and respiratory decompensation earlier in the visit requiring increased resources/monitoring, etc.. , a query would be indicated and appropriate at that point.
From 2013 AHIMA Guidelines for Achieving a Compliant Query Practice:
When and How to Query
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 xx Is unclear for present on admission indicator assignment
--
Based on above guidelines a Query should be considered in many instances. In a mortality record as was quoted by Dr. La Chaite above clinical indicators noted after comfort care has been initiated (i.e. sats dropping, AMS, no urine output etc) would not be consideration for a query. Look for clues and indicators prior to palliative care and place that query.
Please evaluate your patient regarding the following possible terminal events:
· Cheyne-Stokes respirations
· comatose
· acute renal failure
· respiratory failure
· other specific organ failure
· cardiopulmonary arrest
· other specific terminal events
Do you ask if these events are r/t comfort care or the active dying process? Do you ask if these events were present prior to being "terminal?'
Charlene,
Thank you for that. The query practice brief is an indispensable resource. Actually, I was looking for something more specific r/t the timing of queries like resp failure and coma in the dying process. At what point in the medical condition does it become "unethical" to query? I wanted to know if there was any official current stance on this.
Concur w/ Kerry: We don't query after drugs and medications on-board in order to provide peace and comfort...these interventions will induce various conditions that are intended, and are not diseases or disorders; hence, not to be coded...purpose of coding is to report morbidity and mortality, and something such as an induced coma state is a desired intent and outcome.
Paul Evans, RHIA, CCDS
Have you used the SEARCH function and scanned the ACDIS Library? You may find a definitive opinion or paper in our resources that you could use as a reference. I believe the common practice amongst most is as stated by Kerry, but not aware of a Black and White Rule...bear in mind coding is designed to report causes of morbidity/mortality...one example: we all die with 'cardiac arrest', but it is a normal process and not always 'reportable'. Just my opinion.