Diagnosis that are documented but may not be there

chwcdi

Curious to see what other institutions do when you come across a chart and the provider has a diagnosis documented, but perhaps your institutional definitions do not back up the diagnosis actually being in the chart. One example, we have a lot of physicians documenting AKI. Sometimes the BUN and Creatinine do not match our institutional definitions of AKI and then we end up getting denials. Do CDIS usually send a form of query to have them remove a diagnosis or is it more of a one-on-one discussion to remove the diagnosis.

evanspx@sutterhealth.org

I issue a 'query' to the MD.   There is an excellent resource from ACDIS that offers insight on such situations.  Go to the Home Page and use the 'search' feature for 'clinical validation'.

Paul Evans

CCDS

afrady@blr.com

Both coding clinic and the AHIMA practice brief on query states that in such cases a query should be placed.   One of the coding clinics is as recent as (I believe) 4thQ 2017 where it clearly states if an MD has documented a condition that does not appear to be supported by clinical indicators in the record, the Physician "should" be asked to document his "rationale".  It may be a legit diagnosis presenting in an atypical presentation, and this gives the Physician an opportunity to further document his expertise and thought process in telling a story.  This process is now pretty much a requirement of reporting guidelines.  

izusman

Unfortunately one of the problems associated with the implementation of EHR is the fact that diagnoses from the previous encounters can be carried into the current encounter when the Problem List is not appropriately updated.

Even when the condition is presented somewhat atypically, there should be an evidence that this diagnosis was addressed during the current stay. I would suggest to follow the coding guidelines for reporting of secondary diagnoses and check if there is an evidence of::

Clinical evaluation

Therapeutic treatment

Further evaluation by diagnostic studies, procedures, or consultation

Extended length of hospital stay
Increased nursing care and/or other monitoring

If there is an evidence of treatment or monitoring, then issuing a query will be appropriate.

Irina Zusman

lprescott1

https://acdis.org/resources/clinical-validation-and-role-cdi-professional

ACDIS has published a white paper on clinical validation.