Query answered without clinical validation

proddy@clarionhospital.org

Hi,
I don't remember what I was reading yesterday (probably here on ACDIS somewhere) and came across information from Coding Clinic 4th Quarter 2017 pg 110: "If after querying, the attending physician affirms that a patient has a particular condition in spite of certain clinical parameters not being met, the facility should request the physician document the clinical rationale and be prepared to defend the condition if challenged in an audit. The facility should assign the appropriate code(s) for the conditions documented."
Interested in how others handle this type of situation.  Do you escalate this to your physician advisor/champion to address with the attending, or does CDI address it first and only involve the phys advisor if unable to get cooperation from the attending?
Thanks,
Peggy

proddy@clarionhospital.org

anybody?

afloyd24

We don't have a physician advisor so it is left to us to tackle.  We have a good relationship with our Hospitalist program so we refer all of their queries back to them to defend if not clinically sound.  If it is from a provider who is not employed by the hospital, we are at their mercy to defend or not.  Win some, lose some.

lprescott1

I would suggest you speak to the provider- identifying that the documentation is vulnerable to denial based on clinical validity and that clinical support rational should be provided in support of the diagnosis.

Give them a formula to document- state diagnosis as demonstrated by..... with a treatment plan of ....

proddy@clarionhospital.org

Thanks Laurie