Query to PA
I have just received a denial from Humana regarding a Query I sent for Malnutrition. The PA documented Malnutrition Moderate-Severe on the Discharge Summary. I sent the PA a query asking which one we should be coding based on clinical indicators/dietician assessment/etc. She documented Severe.
Humana said they will not accept this because the attending physician must sign this query also? I have never had any issues with this before.
I cannot find any support from AHIMA on this topic. Any helpful suggestions for appeal? Or would appeal not be appropriate?
Thank you!
Brittany Lopez
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Comments
I would contest, asking them to provide the basis for the denial.
If your State and Medical Staff By-Laws permit a PA to independently render a diagnosis, a query to the PA is compliant. I would send them a copy of State and Facility Regulations and By Laws stating same.
One exception might be we need to send a query to the Attending if there is 'dissonance' amongst providers authorized to render a diagnosis, and this needs to be resolved so that the proper coding is applied.
I have not searched the decades of Coding Clinic as I respond, but I am not aware of an issue per C. Clinic stating we are 'not' permitted to query NP, PA.
The key is to point out, if this is the case, that a PA is authorized at your site to render a diagnosis. My response is assuming the PA notes do not require countersignature...again, check with Medical Staff and perhaps even touch base with HIM Deficiency Team.
O/W, I don't see a basis to deny.
Good luck.
P. Evans, RHIA
CODING CLINIC FOR ICD-10-CM/PCS
VOLUME 1 FIRST QUARTER
NUMBER 1 2014, Page 11
Documentation Issues from Coding Clinic
Question: Can you clarify whether advice on documentation issues that do not appear to be specifically tied to a particular coding system (ICD-9-CM nor ICD-10-CM/PCS) are still valid for ICD-10-CM or ICD-10-PCS?
Answer: Coding Clinic advice regarding documentation issues over the years has focused on what documentation can be used and was not specific to a coding system. For clarification purposes, the following information is being republished.
· Provider Documentation
Code assignment may be based on other physician (i.e., consultants, residents, anesthesiologist, etc.) documentation as long as there is no conflicting information from the attending physician.
Medical record documentation from any physician involved in the care and treatment of the patient, including documentation by consulting physicians, is appropriate for the basis of code assignment. The issue of whether a resident’s documentation needs to be confirmed by the attending physician is best addressed by the hospital’s internal policies, medical staff bylaws, and/or any other applicable local/state/federal regulations.
Documentation is not limited to the face sheet, discharge summary, progress notes, history and physical, or other report designed to capture diagnostic information. This advice refers only to inpatient coding.
It is appropriate to use the completed cancer staging form for coding purposes when it is authenticated by the attending physician.
It would be appropriate to use the health record documentation of other providers, such as nurse practitioners and physician assistants as the basis for code assignment to report new diagnoses, if they are considered legally accountable for establishing a diagnosis within the regulations governing the provider and the facility. The Official Guidelines for Coding and Reporting define a provider as the individual legally accountable for establishing a diagnosis.
It is appropriate to assign a procedure code based on documentation by a nonphysician professional when that professional provides the service. This may be the only evidence that the service was provided. For example, infusions may be carried out by a nurse, mechanical ventilation may be provided by a respiratory therapist, or a drug may be ordered by the physician and administered by a nurse. Please note this only applies to procedure coding where there is documentation to substantiate the code. This advice does not apply to diagnosis coding.
· Coding on the Basis of Up or Down Arrows
It is not appropriate for the coder to report a diagnosis based on up and down arrows. Diagnosing a patient’s condition is solely the responsibility of the provider. Up and down arrows can have variable interpretations and do not necessarily mean “abnormal.” They could simply be indicating change (including improvement) over past results. Therefore the provider should be queried regarding the meaning of the arrows and request that the appropriate documentation of a condition or diagnosis be provided. This information is consistent with the coding guideline on abnormal findings which states: “abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added.”
The same advice applies for both inpatient and outpatient admissions.
Coding advice or code assignments contained in this issue effective with discharges March 31, 2014.
Coding Clinic above provides specific advice:
It would be appropriate to use the health record documentation of other providers, such as nurse practitioners and physician assistants as the basis for code assignment to report new diagnoses, if they are considered legally accountable for establishing a diagnosis within the regulations governing the provider and the facility. The Official Guidelines for Coding and Reporting define a provider as the individual legally accountable for establishing a diagnosis.
Thank you so much for this information Paul. This was very helpful! Have a great day.
Brittany Lopez
Paul
Hi Paul,
Humana said this denial is based on the following: The Query does not indicate it is a permanent part of the medical record. The response is not documented in the medical record itself. And the Query was signed by the PA, there was no attending physician signature and date.
I clarified our hospital bylaws, and it does appear we need the physician to sign off on ALL PA/NP entries into the medical record. We were told originally, if the information did not conflict with the attending, we were ok, but it appears that information is not correct.
Our Queries were never part of our medical record, until 2 years ago. Our Quality/Risk team approved a new policy, that our Queries are part of the medical record, but NOT part of the legal medical record. They are sent with the charts for insurance/billing purposes.
Take away from this: 1. Do we need to add a phrase to our Electronic Query Form, that says Queries are not part of the Legal Medical Record? Or does our policy cover this? We need to research this more and possibly make changes.
2. Our PA/NP must also have the MD sign off on ALL Queries. We were currently only doing this if conflicting.
3. I can ask the physician to review this account again, and sign, date, time, but this will be 7 months after the patient was here.. and I doubt that would be accepted?
I am the only CDI Specialist at our facility, and I rely heavily on our Coding auditors, CDI consultants to help review policy/procedure, etc... doing all of this and reviewing daily charts can be very overwhelming!
Thank you again for your input.
Brittany Lopez
Hi, Brittany
Based on the new information provided (PA notes must be countersigned per your bylaws), I personally understand why the case was denied. Some of the issues you are raising should be addressed in a facility P&P with reviewed and approval by Senior Executives, Compliance, Legal Advisors. I certainly can provide my opinion, but I am not a Lawyer. I personally have learned much about this profession by participating in these blogs, attending seminars, and purchasing CDI products from AHIMA and ACDSI. It would be difficult, in my opinion, to work as the sole CDS in a facility; I have many strong CDS partners from whom I can draw experience and opinions, and our CDI teams work closely with our Compliance Team. I say this because the fundamental questions you raise about aspects of the query should be directed to an engaged Compliance Team, and reflected in a written policy.
I'd personally not refer this back to the MD given the time lag you just cited, but others may disagree. I can't tell you if the query should or should not be a permanent part of the record; but, I can tell you personally my preference is that the query be a permanent part of the record. I believe that a query that cites context, strong clinical content, and offers compliant choices should be a permanent part of the record; if the query is properly constructed using Best Practices (AHIMA), it should lend strong support for the subsequent code assignment.
Best,
P Evans, RHIA, CCDS