Does anyone have an escalation process for when Quality and CDI/Coding are at odds?
As I understand it, sepsis quality measures reflect improvement when the denominator, all sepsis cases, is higher. In some cases quality is trying to influence CDI to query and coders to assign codes for sepsis when it is documented one time, in the ED or even if there is ?sepsis in the ED.
Does anyone have an escalation procedure outlining how to handle instances when quality does not agree/accept CDI or coding decisions?
Does anyone have an escalation procedure outlining how to handle instances when quality does not agree/accept CDI or coding decisions?
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My opinion, coding ALWAYS has final say. Even when I have worked in CDI within the quality dept (with extensive collaboration with quality and reporting to quality myself), I have always reinforced to leadership that coding is responsible for assigning codes. We can certainly discuss whether those codes are valid/correct, make our case, etc, but quality has no authority over coding (neither does CDI in most hospital structures). Coders are putting their name on that record and they will be held accountable for inaccuracies in code assignment. Therefore, they get final say.
The reason I say this in response to your question (though I know that's not what you were asking) is that the idea that there should be escalation OUTSIDE of coding, to me is problematic. Physicians, RN's, and other staff that may be included in an alternative escalation process may not be well versed in coding/documentation guidelines and it would be inappropriate for them to have that kind of oversight. Let's say the escalation policy goes to the CMO.... Who will then assign the codes that he/she recommends? Who will be accountable for them? I am not trying to be argumentative but I would have serious issues with a process that took final code assignment away from coding. I am all for discussion/collaboration/multidisciplinary teams that would assist in assessing the situation and identifying possible solutions. But code assignment belongs to coders.
A better way to approach these issues to work with CDI/quality/physicians to develop clear sepsis definitions that establish when a query will/will not be placed and to focus on clear consistent documentation. Also important for those who are outside of CDI/coding understand that diagnoses without strong clinical indicators of sepsis, will likely be denied by the insurer regardless of documentation of sepsis by the provider...
my 2 cents....
Katy
I endorse Katy's thoughts on this complicated issue. Briefly, must bear in mind the somewhat nebulous nature of any definition for 'sepsis'. As such, if sepsis is mentioned only once, but not repeated, it would be prudent to proceed as per recommendation from Katy, IMO. The documentation and coding of sepsis is being heavily scrutinized. I would advocate that organ dysfunction(s) that are associated with sepsis be clearly linked as such, as this may help establish the condition.
Paul