How timely. I just sent a newsletter out to the providers here today on that very subject.
I always query if I see acute changes or if there are chronic changes that are not clear or documented. But it also depends on if those conditions are impacting the patients care and are being treated during the admission.
Here is the booklet I included with the newsletter. Feel free to use it as a reference.
Robert
Robert S. Hodges, BSN, MSN, RN Clinical Documentation Improvement Specialist Aleda E. Lutz VAMC Mail Code 136 1500 Weiss Street Saginaw MI 48602
I have talked with our doctors about the RIFLE criteria but our lead nephrologist feels that the absolute standard for ARF is a 0.5 increase in the serum creatinine, with or without symptoms, and that is what he has told our hospitalists. I just had to write an appeal of a denial of 584.9 for not meeting RIFLE criteria; it will be interesting to see how it comes out.
We are constantly having discussions between the coders and the CDI staff about questionint a physician about a diagnosis that has not been identified yet. i.e. CDI looking at labs and questioning if this would warrant a specific diagnosis? Do you have the same conversations?
Every day! I guess the most popular one is whether or not a patient is septic or not. So many times by the labs it looks like they could be, but it's not being documented so I have to ask that often. The hardest for me is acute kidney failure. I am still trying to educate myself on this one.
We actually have the opposite problem. Our docs seem to document too much sepsis. Can anyone give me some feedback from a coder standpoint about sepsis. We are meeting with our Through-put director after reviewing a sample of "sepsis" charts. She states that sepsis is a clinical judgment from the doctor and therefore if they say it's sepsis it is. From a coding perspective does the patient have to meet SIRS criteria? I understand that if the doctor writes something it can be coded but thinking about RAC I worry about that. Thanks for your input.
All the time, but to be honest, sometimes the doctors will depend on me to catch things they miss. As I've told them, I'll ask about a lab and if it is something that is being treated and impacts the patients care, but it's up to them to make that decision.
Robert
Robert S. Hodges, BSN, MSN, RN Clinical Documentation Improvement Specialist Aleda E. Lutz VAMC Mail Code 136 1500 Weiss Street Saginaw MI 48602
We Query the physician. Our Query contains the Clinical Indicator with which we are comparing the lab data. It's an education tool (if they read it) as well as documentation prompt.
N. Brunson, RHIA Clinical Documentation Specialist Bay Medical Center
I am curious how any of you out there keep track with your queries and what impact they have on the DRG. Do you simply go from beginning working DRG and final DRG and figure the increase/ decrease? I am trying to figure out how to show the impact the CDI program makes. Any help?
We take the beginning DRG relative weight and the final DRG relative weight that changed only because we clarified documentation, multiple each by your facilities blended rate, and subtract, that will give you your impact. Our software does the math for us (thank goodness!!!!). Susan Tiffany RN, CDS Supervisor Clinical Documentation Program Robert Packer Hospital & Corning Hospital Tiffany_Susan@guthrie.org
I track all of my clarification requests in my database and then send copies to the inpatient coders each day along with any response I see documented by the providers. They then fill out a worksheet each month that I provide to document if a MCC or CC was captured, a more precise code was applied, or another change resulted from the request. I then plug that information back in my database and report out on it each month.
It's a little time intensive, but they have a few weeks to complete the worksheet and it does show where a clarification request has made an impact on the coding.
Robert
Robert S. Hodges, BSN, MSN, RN Clinical Documentation Improvement Specialist Aleda E. Lutz VAMC Mail Code 136 1500 Weiss Street Saginaw MI 48602
One cannot use the "beginning DRG" or "working DRG". After discharge, need to review the coding summary and determine what ICD-9 code you specifically contributed by your query and then decide what / whether that additional code BY ITSELF caused a DRG change. From this, the final DRG is the one coded, the intial DRG is what would have been without your added code.
The 2 broad things behind this: The CDI beginning or working DRG may not be accurate due to additional information, something the CDI missed on the floor, discharge status influence on payment (transfer DRGs)......... Secondly, by looking at the actual coding summary you are ensuring what you think you added you actually did.
We review our attestations and compare with our worksheet. If our query impacted the DRG we log it as such and note the DRG increase. Most of our queries do not impact DRG though -the average is about 5%,
The software program - CDI Monitor - that we use is from Navigant Consulting - and in it the CDS staff enters their queries, and the different DRG which would result. Of course, not all queries result in a positive response, but we start with our "working DRG" and then end up with a "CDS DRG" to show the query activity - sometimes, these DRGs are the same, but if a query has been done, they should be different---unless the query is just for severity of illness, perhaps. If coders happen to query retrospectively, they also enter their queries into the software - and we all have access to the records in the software, so we can "track" the entries, and responses to the queries.
There are also a multitude of reports available through the software that allows us to review our financial impact, queries done, types, etc.....it's a pretty robust program!
I think there are as many different ways to do this job as there are those of us doing it. I don't think there is any "right" or "wrong" way - it's just how your program works, what works best for your facility (with the setup/support you have in place) and all the improvements we make along the way.
It is actually part of our software. We look at the initial CDS DRG vs the final billed DRG if there was a query. Before the software we kept a manual record of this. Hope this helps.
Just as it's not appropriate to query for a diagnosis based solely on a radiology report, I think it's probably not ok to ask for a diagnosis based solely on labs. Sometimes they're just numbers. I try to give the physician an opportunity to review the labs and make a clinical judgment before presenting him/her with a query. There should also be some type of treatment or impact on the patient stay as a result of the labs before asking for it as a cc/mcc. For instance, I stopped asking for ABLA postoperatively unless the physician orders transfusions or has to treat the bleeding/anemia in some way. I still do plenty of ARF and ABLA queries with labs as support, but I think there needs to be a whole picture around those queries and not just numbers.
I hear what you are saying and agree. A lot of my lab based queries are based on my ability to see lab values over the past 2+ years. The pleasure of having a longitudinal electronic medical record. If a patient is at baseline I'm far less likely to query, unless it may add a cc or mcc to the drg, than if I see an acute change from baseline. But in all cases I ask the provider to review and if it is clinically significant and is something they are treating if they can address and clarify it in their documentation.
My providers are busy and so I try to keep the queries focused on something that either impacts the quality of the documentation or will impact the final coding in some way.
Robert
Robert S. Hodges, BSN, MSN, RN Clinical Documentation Improvement Specialist Aleda E. Lutz VAMC Mail Code 136 1500 Weiss Street Saginaw MI 48602
We had our internal IS dept. build us an Access Database. Works well for tracking, have minimal info we have to load as alot of it is pulled from our billing info (Star). We are able to show our CFO the realized queries as well as the impact our department is having to the "botttom line"
Comments
I always query if I see acute changes or if there are chronic changes that are not clear or documented. But it also depends on if those conditions are impacting the patients care and are being treated during the admission.
Here is the booklet I included with the newsletter. Feel free to use it as a reference.
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
"To climb a steep hill requires a slow pace at first." -William Shakespeare
D. Smith RN, CDIS-CM
Linnea Thennes, RN, BS, CCDS
Clinical Documentation Specialist
Clinical Resource Management
Northwest Community Hospital
847.618-3089
lthennes@nch.org
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital
much sepsis. Can anyone give me some feedback from a coder standpoint
about sepsis. We are meeting with our Through-put director after
reviewing a sample of "sepsis" charts. She states that sepsis is a
clinical judgment from the doctor and therefore if they say it's sepsis
it is. From a coding perspective does the patient have to meet SIRS
criteria? I understand that if the doctor writes something it can be
coded but thinking about RAC I worry about that. Thanks for your input.
Gina Spatafore, RN
Clinical Documentation Integrity Specialist
Waterbury Hospital
203 573 7647
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
"To climb a steep hill requires a slow pace at first." -William Shakespeare
which we are comparing the lab data. It's an education tool (if they
read it) as well as documentation prompt.
N. Brunson, RHIA
Clinical Documentation Specialist
Bay Medical Center
what impact they have on the DRG. Do you simply go from beginning
working DRG and final DRG and figure the increase/ decrease? I am trying
to figure out how to show the impact the CDI program makes. Any help?
weight that changed only because we clarified documentation, multiple each
by your facilities blended rate, and subtract, that will give you your
impact. Our software does the math for us (thank goodness!!!!).
Susan Tiffany RN, CDS
Supervisor
Clinical Documentation Program
Robert Packer Hospital & Corning Hospital
Tiffany_Susan@guthrie.org
It's a little time intensive, but they have a few weeks to complete the worksheet and it does show where a clarification request has made an impact on the coding.
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
After discharge, need to review the coding summary and determine what ICD-9 code you specifically contributed by your query and then decide what / whether that additional code BY ITSELF caused a DRG change. From this, the final DRG is the one coded, the intial DRG is what would have been without your added code.
The 2 broad things behind this:
The CDI beginning or working DRG may not be accurate due to additional information, something the CDI missed on the floor, discharge status influence on payment (transfer DRGs).........
Secondly, by looking at the actual coding summary you are ensuring what you think you added you actually did.
Don
There are also a multitude of reports available through the software that allows us to review our financial impact, queries done, types, etc.....it's a pretty robust program!
Hope that makes sense?
Becky Mann
Queen of the Valley Medical Center
Becky Mann
MD no response rates, clarification rates, agree vs disagrees and such.
Susan Tiffany RN, CDS
Supervisor
Clinical Documentation Program
Robert Packer Hospital & Corning Hospital
Tiffany_Susan@guthrie.org
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
the final billed DRG if there was a query. Before the software we kept a
manual record of this. Hope this helps.
Gina Spatafore, RN
Clinical Documentation Integrity Specialist
Waterbury Hospital
203 573 7647
Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital
I hear what you are saying and agree. A lot of my lab based queries are based on my ability to see lab values over the past 2+ years. The pleasure of having a longitudinal electronic medical record. If a patient is at baseline I'm far less likely to query, unless it may add a cc or mcc to the drg, than if I see an acute change from baseline. But in all cases I ask the provider to review and if it is clinically significant and is something they are treating if they can address and clarify it in their documentation.
My providers are busy and so I try to keep the queries focused on something that either impacts the quality of the documentation or will impact the final coding in some way.
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
"To climb a steep hill requires a slow pace at first." -William Shakespeare
Mandi Robinson RN, BS
Clinical Documentation Specialist
Trover Health System
270-326-4982
"Excellent Care, Every Time"