Outpatient documentation use for inpatient queries

Lori.Drodge@mainehealth.org

Having read the “Guidelines for Achieving a Compliant Query Practice (2016 Update)” from AHIMA and “Physician Queries and the Use of Prior Information: Reevaluating the Role of the CDI Specialist” from ACDIS, I am still thinking about this topic. Coding Clinic 3Q13p27-28 indicates, “if the condition is not documented in the current health record, it would be inappropriate to go back to previous encounters to retrieve a diagnosis without physician confirmation”.  This infers that it may be a compliant practice to incorporate this information into a query that could then be coded if there is physician confirmation.  For example, if an echo was done a week prior to admission and only CHF without more detail is noted during the inpatient stay, is it compliant to compose a non-leading query that includes the outpatient EF% (the clinical indicator needed) to define the type of CHF? 

Another example is:  a patient is found to have brain cancer with cerebral edema 2 days prior to admission and is placed on Dexamethasone.  The patient is then admitted for cancer resection and the medication list includes Dexamethasone.  Is it compliant to query for the indication of the medication using the prior outpatient note?  The query might read:  The patient has known glioblastoma multiforme.  An outpatient visit 2 days prior to the admission documents a lesion with surrounding edema and is not very symptomatic since starting steroids.  The H&P notes continued use of Dexamethasone.  Is this medication currently treating:  Cerebral edema, other condition (please specify) or unknown. 

I look forward to your thoughts! 

lostwater

I read the guidelines to ensure that we do not attempt to report a diagnosis that is not relevant to the current stay, or a diagnosis that is not present.  I have not seen the guidelines to prohibit us to include relevant, accurate clinical information that may be elsewhere, for example the EF from the outpatient visit yesterday.  With more standard care being moved into the outpatient environment, we will continue to rely on the entirety of the patient's clinical course.