Industry experts in CDI seem to be rewriting and reinterpreting official rules.
Disclaimer: I do not post in the forums much as I have a skeptical side, tend to think for myself, like to destroy the paradigm and challenge people to get outside of their previous understanding. Nonetheless, in the spirit of increased cooperation, I offer this issue which I find genuinely confusing up for discussion. You will notice I asked more questions than I answered. The questions are not rhetorical...I genuinely want to know these answers. Thank you in advance.
I have been hearing teaching in conflict with what I perceive as the official guidelines as set out by the four cooperating parties and am seeking the input of experts and critics alike.
These issues do not appear to be confusing to me, and have in fact, been pretty much the same for at least the 20 years I have been reviewing records.
I know some people are concerned about having guidelines “interpreted” through the eyes of the person who is complaining so I will lay out my interpretation process in great detail here. Try to keep up. I used A) A copy of an Oxford English dictionary and 
The official coding guidelines from the AHA and C) The 2016 AHIMA practice brief. Nothing else.
You may be wondering what my issue here is. Well, the problem is that I am hearing these talking points from industry leaders, experts, thought leaders, consultants, teachers etc. Yet I cannot find the source of this talking point that is being repeated every where. When I look to the references they seem to be citing, they do not say what these well respected sources claim they say. As the pedant that I some times can be, you might imagine this causes me great anxiety.
Let’s do a point counter point:
1) Timing Issue
-Official Advice: Uncertain diagnoses written AT THE TIME OF DISCHARGE are reported.
-"Talking point" Advice: Uncertain diagnoses only count if dictated in the discharge summary.
Discussion: Does “At the time of discharge” mean “Only in the discharge summary”? Are progress notes written on the final date of service also not “at the time of discharge”? When discharge summaries are written up to 24 hours prior and up to two weeks after discharge….do they even count as “at the time of discharge”? If you want to get technical, one might even argue that a discharge summary should be excluded unless it is written within 1 hour of the discharge order. CERTAINLY one would think it might be excluded (based on this wording in the official guidelines) when dictated prior to or several days AFTER discharge right? Of course that is absurd right? Is it MORE absurd than the claim that progress notes written within a 24 hour rolling clock of that discharge order are somehow NOT “at the time of discharge”? Is the discharge summary actually the only way to measure “at the time of discharge”? Are intelligent people not capable of reading and considering the final day’s progress notes? Is something hard about reading the final date of service progress notes that I am unaware of?
2) The uncertain diagnosis of “possible”
-Official advice AHA: “If the diagnoses documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out” or other similar terms indicating uncertainty” (at the time of discharge)...they can be reported.
-"Talking point" advice: “Never use possible even when in the discharge summary”.
Discussion: Here I think it is pretty obvious. The consultant advice is clearly wrong. However, this addressing coding and not query writing. There is more to the story. (See next section).
3) The uncertain diagnosis of “possible” part II
-Official advice AHIMA (on queries): “Possible is a very broad term and therefore its use in a query is discouraged”.
-"Talking point" Advice: “Never query for possible”
Discussion: Now I don’t mean to nitpick but “discouraged” and “forbidden” are not the same thing. Fine, we will discourage it. What does “discourage mean”? It appears to me to be saying avoid over use, inappropriate use, and use when it could be vague. However, that would also imply that it should be allowed in situations where completely appropriate (at least that is what I inferred from it being implied). When would it be appropriate? Again, that would appear to be obvious: It would be appropriate as a term when there was a strong evidence based clinical suspicion of the diagnoses presence but without the certainty to diagnose definitively…i.e. “possible”. I think many prefer the term “probable” which I agree is better. What I do not agree with is making the “absolute” statement that it is forbidden when that is clearly NOT what the advice says. I am not sure why this is so hard. Help me out. Is it what I refer to as the logical fallacy of brevity? Just giving the shortest answer which is right 80% of the time but unfortunately ends up being wrong 20% of the time? I suspect this could be what is at play here.
Let’s step away from the minutia for a minute and ask the big questions:
Are we talking about dealing with commercial insurance entities which do not conform to CMS guidelines and/or which do not have any sort of standard requirements which apply to their operating policies? Are we letting auditors dictate real world coding policy in violation of CMS official guidelines? Are “best practice” advice talking points out of synch with official reporting guidelines to simply keep clients out of trouble? If so, does that not give auditors cart blanche to continue abusing the providers? Does it not embolden them to make even more ridiculous “modifications” on what they will accept? Are we not creating more problems by capitulating? When you feed a monster, the monster only grows and needs to feed more! Is it even appropriate that we should need to make best practice recommendations which are not “word for word” in synch with official CMS guidance to avoid denials? Where do we draw the line? Do we begin simply rewriting all official coding guidance, allowing best practice guidance to violate or supersede? Perhaps we should venture into the wild west of having every payer have different requirements and as a result, everyone playing a shell game of “reword the chart”? Why stop there? Why not ignore the four cooperating parties’ standards completely? I prefer to hold the line at a word for word literal enforcement of the guidance if at all possible. I do not see where the issues here would be “impossible” to comply with. Perhaps people think that complying successfully with this is just “improbable” *wink*.
If the guidelines are truly that bad, perhaps the simple answer is to finally update the guidelines. Is that asking too much?
Aside from outpatient reporting rules (which we all know are completely different here) are there a different set of rules out there which address these issues differently? If so can you point me in the right direction?
Also let me know, who is doing the “interpreting”? Is it me? Or the consultants? You be the judge. Sound off!!!
It is entirely possible I am wrong, please CITE YOUR SOURCES. I don't do heresay or "so and so said" or "just because" or "it's always been".
Thank you.
Comments
Alright, I expected to be proven wrong (as argumentative as I sounded).....
In my best Frasier Crane voice: "Immmm listening....."
In with another talking point that is relevant. My argument above applies to facility billing but not physician billing. Could that be the issue? Are the Physician consultants and experts erroneously lumping "all documentation" into the physician billing talking point? Are we just giving facilities the professional billing rules? If so that is not how it works right???
I was hoping someone would prove me wrong but so far...crickets.
"Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms,signs, abnormal test results, or other reason for the visit. Official guidelines for Coding and Reporting, Section IV. H. (outpatient rules)– Why different guidelines for physicians and hospitals? Any possible consideration for change in the future as hospitals and physicians align under initiatives like ACOs?"1. Timing Issue
-Official Advice: Uncertain diagnoses written AT THE TIME OF DISCHARGE are reported.
-"Talking point" Advice: Uncertain diagnoses only count if dictated in the discharge summary.
The rule is that it needs to be in the discharge summary or last note..BUT WHAT CAME OUT NEW REGARDING HCCs said it absolutely had to be in the discharge summary for risk adjustment. I am guessing this rule can be found on CMS where the list of HCCs is located... maybe someone can link to that location?
2. uncertain-here it explains the inpatient , outpatient difference
(official coding guidelines)
If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.
3. Uncertain - part 2. I AGREE IT'S SILLY. the position paper should not override the coding guidelines. The solution (if a solution were actually desired) would really not be that hard. Either a) don't advise an entire industry to disallow a word stated in coding guidelines, or b) get rid of possible as counting as a phrase that would allow for coding...
And if someone bothers to fix that easy fix... they could define Encephalopathy, and make a code for HCAP pneumonia... makes you wonder how much of a desire there IS to fix certain things.
I am not sure I got your distinction between uncertain "possible" 1 and 2 but that was my best guess...
4. Another frustration is the not introducing anything from the old record... Doctors and CDIs look at labs and see the past- which tells trends and presents the most accurate patient story.
Even though "The guidance of this practice brief augments and, where applicable, supersedes prior AHIMA guidance on queries. The intent of this practice brief is not to limit clinical communication for purposes of patient care. Rather it is to maintain the integrity of the coded healthcare data. All professionals are encouraged to adhere to these compliant...".... "Clinical indicators should be derived from the specific medical record under review and the unique episode of care. Clinical indicators supporting the query may include elements from the entire medical record, such as diagnostic findings and provider impressions.
A query should include the clinical indicators, as discussed above, and should not indicate the impact on reimbursement. A leading query is one that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or procedure. The justification (i.e., inclusion of relevant clinical indicators) for the query is more important than the query format."
Common sense too often disappears- the patient's past CKD, Creatinine and weight being "disallowed" in the name of compliance actually does a disservice to patient care.
As health care providers we always learn to look at the whole patient, trends, what is normal for them. This is why providers look at the H&P, past visits, to care for the entire patient, to make the best decision for that patient.
The rules get twisted and dissected and spun repeatedly. Is it really for the good of the patient? I understand not coding a comorbidity from the past but if common sense paints a picture of a patient with CKD because they have an elevated creatinine, and CHF on ace inhibitors... I feel we miss the boat on getting an accurate record by pretending the labs are not in front of us. (I am aware of person's position that say.. "if the doctor wanted it in the record he could have put it in there", which is coincidentally just what doctors ( who never get on board) say when we query. My only point is, it's really not that simple and straight forward, regardless of when that is said).
I understand the comments regarding "best practice" and I don't in theory have a problem with them, but the fixation often distorts the intent. "The justification (i.e., inclusion of relevant clinical indicators) for the query is more important than the query format." .
oh well... job security
I have searched for this rule and cannot find it. If anyone has a link, please post! We can then have a different conversation about Medicare Part A rules vs Part C!!
Also, have you reviewed the ACDIS white paper on use of old records? Perhaps a topic for a separate discussion!
But this does get a bit murky, because what would happen if later documentation from another encounter would rule out the uncertain diagnosis? We would have a conundrum where an incorrect risk profile would be propagated. This is likely a moot point and controlled in the overall model as the next year the diagnosis would not be picked up (hopefully) and as the risk is spread across the population, some variance is appropriate in a single case.
Nevertheless, the HCC model does account for this as acute conditions are often lumped into the same condition categories as their chronic cousins, and, acute conditions are overall weighted less than chronic conditions in this risk model.
Mark
Mark,
If an uncertain diagnosis is stated as ruled out, in any part of an inpatient record it is not coded. I am resurrecting this conversation as I have something update worthy to add.
Attached is the AHA's opinion on the matter.
Here the AHA defines it not by it's place in the record (IE, in the discharge summary or progress note) but by the timing of the note. "The time of discharge implies the patient has been evaluated, treated and is ready for discharge from the facility." This would imply that my argument that the guidance stating "at the time of discharge" CAN be from the final days progress notes is indeed the correct interpretation.
I still wouldn't suggest anyone fight my battle of "we must be allowed to obey the guidelines" to the financial detriment of your facility. I would however, fight any denials on this basis all the way to the insurance commission and my congressman until such time as either the practice is adjusted to match the guidelines or the guidelines are updated to match what the auditors are saying.
I wanted to follow up on this one. I had almost forgotten about my search into this problem earlier in the year. I received an answer from the American Hospital Association which defined "at the time of discharge" by the circumstances surrounding the decision to discharge the patient and the discharging date but not by any particular piece of documentation. Be that as it may, I have surveyed many industry insiders and experts in the interim and have not seen or found anyone willing to entertain the idea that an uncertain diagnosis could or should be located any where but within a discharge summary. What we have here is a clear disconnect between the exact wording of the guidance and the accepted and expected practice. You will have to err on the side of having them in the discharge summary. In the near future I encourage every one of you to post this question to the AHA in order to attempt to get some official clarity on both uncertain conditions not in the discharge summary but also on the coding of confirmed conditions not in the discharge summary (which also continues to be a problem guidance vs practice).
Thank you.
Richard D. Pinson, MD, FACP, CCS
Pinson & Tang
CDI Educators and Advisers
Authors of the CDI Pocket Guide
www.pinsonandtang.com