Organizational Definitions
We’re looking at the idea of using organizational definitions as a way to avoid the clinical validation query (aka “A Good Way To Annoy Your Medical Staff.”) Specifically, we’re exploring using organizational definitions, adopted as policy by the Medical Staff, as way to avoid the CV Query by using the policy as a coding “default; “ ie. our definition of sepsis is X, the documentation doesn’t meet that criteria, so we’re going to default to code the underlying infection as Principal. Does anyone have any experience with this idea, know anyone who uses it this way, or have any referrals or contacts? I’d really appreciate your thoughts. Thanks!
Comments
I want to do something similar...just have to get over a major EHR implementation first. I am attaching a presentation from last yr's Conference that is about a facility's clinical indicators committee, I hope it helps!
Jeff
My understanding is that coding policy cannot be used this way. You can't, for example, set up a coding policy that's states that ABLA will be coded when there is a 20% drop in H/H 2 days post surgery. Conversely, you cannot have a policy that states that it will ONLY be coded if there is a 20% drop.
Coding must be based on the providers diagnostic statement that the diagnosis is present. Criteria used by the provider to establish the diagnosis is irrelevant. This has always been the case but Coding Clinic specifically addressed this issue in Q42016. Coders are bound by coding guidelines and individual hospital policies cannot override these.
Question:
Please explain the intent of the new ICD-10-CM guideline regarding code assignment and clinical criteria that reads as follows: "The assignment of a diagnosis code is based on the provider's diagnostic statement that the condition exists. The provider's statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis." Some people are interpreting this to mean that clinical documentation improvement (CDI) specialists should no longer question diagnostic statements that don't meet clinical criteria. Is this true?
Answer:
Coding must be based on provider documentation. This guideline is not a new concept, although it had not been explicitly included in the official coding guidelines until now. Coding Clinic and the official coding guidelines have always stated that code assignment should be based on provider documentation. As has been repeatedly stated in Coding Clinic over the years, diagnosing a patient's condition is solely the responsibility of the provider. Only the physician, or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis, can "diagnose" the patient. As also stated in Coding Clinic in the past, clinical information published in Coding Clinic does not constitute clinical criteria for establishing a diagnosis, substitute for the provider's clinical judgment, or eliminate the need for provider documentation regarding the clinical significance of a patient's medical condition.
The guideline noted addresses coding, not clinical validation. It is appropriate for facilities to ensure that documentation is complete, accurate, and appropriately reflects the patient's clinical conditions. Although ultimately related to the accuracy of the coding, clinical validation is a separate function from the coding process and clinical skill. The distinction is described in the Centers for Medicare & Medicaid (CMS) definition of clinical validation from the Recovery Audit Contractors Scope of Work document and cited in the AHIMA Practice Brief ("Clinical Validation: The Next Level of CDI") published in the August issue of JAHIMA: "Clinical validation is an additional process that may be performed along with DRG validation. Clinical validation involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented in the medical record. Clinical validation is performed by a clinician (RN, CMD, or therapist). Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder. This type of review can only be performed by a clinician or may be performed by a clinician with approved coding credentials."
While physicians may use a particular clinical definition or set of clinical criteria to establish a diagnosis, the code is based on his/her documentation, not on a particular clinical definition or criteria. In other words, regardless of whether a physician uses the new clinical criteria for sepsis, the old criteria, his personal clinical judgment, or something else to decide a patient has sepsis (and document it as such), the code for sepsis is the same-as long as sepsis is documented, regardless of how the diagnosis was arrived at, the code for sepsis can be assigned. Coders should not be disregarding physician documentation and deciding on their own, based on clinical criteria, abnormal test results, etc., whether or not a condition should be coded. For example, if the physician documents sepsis and the coder assigns the code for sepsis, and a clinical validation reviewer later disagrees with the physician's diagnosis, that is a clinical issue, but it is not a coding error. By the same token, coders shouldn't be coding sepsis in the absence of physician documentation because they believe the patient meets sepsis clinical criteria. A facility or a payer may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but that is a clinical issue outside the coding system.
To your comment, Jeff. I did not attend that session but I believe they were using the committee to develop institutional definitions. These definitions were to be utilized by the medical staff to support diagnosis and by CDI to drive queries.
Am I correct on that or were they actually using these definitions to determine if a diagnosis documented in the record should be coded?
thanks!
Katy
Exactly Katy,
I think I misread the original post...you can't pick and choose when to code. For example, organizational policy states "only code malnutrition if it meets ASPEN criteria", etc.. I want to form a committee to have an organizational consensus on some of the top queried dx's like encephalopathy, ABLA, resp failure, etc.. but only to use those as minimal guidelines to meet to query, not to pick and choose when to pick up a dx. I went back and re-ready the original and realized I breezed through it too fast and gave a response...oops!
Jeff
They were using to develop institutional definitions, that's my intent for our facility one day.
I think the presentation should help you out. Also, if staff are querying with evidence based clinical indicators, then staff shouldn't be querying for an unsupported diagnosis.
Jeff
I think I understand what you are saying, but maintain that you cannot establish a policy that defines a diagnosis and suggest that a documented diagnosis not be coded if it does not meet specific criteria. Institutional definitions are helpful from a physician education standpoint as the process of establishing the diagnosis should include key stakeholders and demand lit review and re-evaluation of how diagnosticians are coming to their diagnoses. They are also helpful from a query standpoint. for example, we adopted sepsis-3 last spring and therefore when patients do not meet sep-3 we reference (in our queries) that this is the definition the facility is utilizing, what the clinical indicators are, and ask them to clarify the clinical indicators that support their diagnosis or select an alternative. But a query is still needed.
The coding guidelines are pretty specific in this area and even if we had created some sort of policy adopting sep-3 and included a coding policy that established that sepsis should not be coded if it doesn't meet sep-3, our coders would still be unable to follow that policy and maintain ethical practice.
Have you discussed this with coding (if your departments are not merged)? I would imagine they would not agree to something like that. Coders have to code what the Dr says. That is not negotiable. If providers are not using defensible criteria to come up with a diagnosis, the solution is to change the documentation (education reinforced by queries). I know that's not the easy solution, we still have sepsis cases fall through the cracks, but these are the coding rules.
Katy
The issue is trying to find a way around the query when the agreed-upon indicators aren't there to support a documented dx. I see where you're coming form, but I think we're looking at this from different ends of the problem.
yes. Querying is not ideal. I just think we have to be careful to practice within practice guidelines. I would love to be able to circumvent clinical indicator queries with established interdisciplinary policies. unfortunately, the guidelines do not permit this.
At some point this could change of course. But considering that the most recent update to the I-10 guidelines specifically added the directive that coders must specifically code what physicians document, regardless of criteria, I don't for see it changing in the immediate future.
19. Code assignment and Clinical CriteriaThe assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.
Katy
Do you have a Physician Advisor? AHIMA's latest white paper one clinical validation suggests that these issues be escalated to a Physician Advisor who can have a peer-to-peer with the Provider that is documenting unsupported diagnoses thus giving them a chance to add an addendum to the record or to firmly stand by their decision and hopefully document a little more of their rationale in the event there's an audit. Patients aren't always textbook and we have to remember that...getting that across to a Provider is key and reminding them a few extra sentences in the record stating their rationale for certain at risk diagnoses can be very helpful in the event of an audit.
Very interested to see what you come up with. We, unfortunately, do not have an Physician Advisor.
Jeff