Can anyone explain the difference between an autogenerated pre-visit form pulled from the EHR that indicates previous HCC diagnoses and suspected conditions vs. a query? Are there guidelines to follow for these forms as well?
Most autogenerated pre-visit forms are usually a listing of conditions (problem list, HCC, PMH) from previous visits and should be utilized for the CDI to work from in their review and for potential query to the provider either during the inpatient admission or in a post outpatient visit. It is not considered a query, It should be used to review and validate those conditions or diagnoses that may still be clinically relevant. Note that depending on your EHR these forms will look different. Some may come from a third-party vendor. Your internal process should be established to give guidance on the purpose and use of these forms. Hope that helps.
In relation to querying, we can refer to the query practice brief which states:
Role of Prior Encounters in Queries Code assignment is not determined by documentation from previous encounters. However, sending a query to clarify documentation using evidence from a previous encounter may be appropriate when relevant to the current encounter. When clinically pertinent to the present encounter, information from a prior health record can be used to support a query. This process reinforces the accuracy of information across the healthcare continuum. However, it is inappropriate to “mine” a previous encounter’s documentation to generate queries not related to the current encounter. Mining would be reviewing a previous health record encounter without a related trigger found in the current encounter. For example, a compliant reason to review previous information (e.g., non-mining), CKD has been documented in the current encounter triggering the need to review previous encounter information to gain further specificity of the CKD. Queries using information from prior encounters may be utilized when relevant in (but not limited to) the following situations: Diagnostic criteria allowing for the presence and/or further specificity of a currently documented diagnosis (e.g., to ascertain the type of heart failure, specific type of arrhythmia, stage of chronic kidney disease [CKD] etc.) Treatment/clinical criteria or diagnosis referenced in the current encounter that may have been documented in a prior encounter: Determine the prior patient baseline allowing for comparison to the current presentation. Establish a cause-and-effect relationship (e.g., clarifying a postoperative complication, exposure to causative organism). Determine the etiology, when documentation indicates signs, symptoms, or treatment that appear to be related to a previous encounter. There is no required number of clinical indicator(s) that must accompany a query because what is a “relevant” clinical indicator will vary by diagnosis, patient, and clinical scenario. Verify POA indicator status. Clarify a prior history of a disease that is no longer present (e.g., history of a neoplasm). When considering whether a query could be issued using information in the prior record, carefully consider the “General Rules for Other (Additional) Diagnoses” that states: “For reporting purposes the definition for ‘other diagnoses’ is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring,” according to ICD-10-CM Official Guidelines for Coding and Reporting, Section III.2 It would be inappropriate to query for a diagnosis that, if documented, would not satisfy this criteria. A query cannot be based solely on the information from a prior encounter. There must be relevant information within the current encounter to substantiate the query.
Comments
Most autogenerated pre-visit forms are usually a listing of conditions (problem list, HCC, PMH) from previous visits and should be utilized for the CDI to work from in their review and for potential query to the provider either during the inpatient admission or in a post outpatient visit. It is not considered a query, It should be used to review and validate those conditions or diagnoses that may still be clinically relevant. Note that depending on your EHR these forms will look different. Some may come from a third-party vendor. Your internal process should be established to give guidance on the purpose and use of these forms. Hope that helps.
In relation to querying, we can refer to the query practice brief which states:
Role of Prior Encounters in Queries Code assignment is not determined by documentation from previous encounters. However, sending a query to clarify documentation using evidence from a previous encounter may be appropriate when relevant to the current encounter. When clinically pertinent to the present encounter, information from a prior health record can be used to support a query. This process reinforces the accuracy of information across the healthcare continuum. However, it is inappropriate to “mine” a previous encounter’s documentation to generate queries not related to the current encounter. Mining would be reviewing a previous health record encounter without a related trigger found in the current encounter. For example, a compliant reason to review previous information (e.g., non-mining), CKD has been documented in the current encounter triggering the need to review previous encounter information to gain further specificity of the CKD. Queries using information from prior encounters may be utilized when relevant in (but not limited to) the following situations: Diagnostic criteria allowing for the presence and/or further specificity of a currently documented diagnosis (e.g., to ascertain the type of heart failure, specific type of arrhythmia, stage of chronic kidney disease [CKD] etc.) Treatment/clinical criteria or diagnosis referenced in the current encounter that may have been documented in a prior encounter: Determine the prior patient baseline allowing for comparison to the current presentation. Establish a cause-and-effect relationship (e.g., clarifying a postoperative complication, exposure to causative organism). Determine the etiology, when documentation indicates signs, symptoms, or treatment that appear to be related to a previous encounter. There is no required number of clinical indicator(s) that must accompany a query because what is a “relevant” clinical indicator will vary by diagnosis, patient, and clinical scenario. Verify POA indicator status. Clarify a prior history of a disease that is no longer present (e.g., history of a neoplasm). When considering whether a query could be issued using information in the prior record, carefully consider the “General Rules for Other (Additional) Diagnoses” that states: “For reporting purposes the definition for ‘other diagnoses’ is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring,” according to ICD-10-CM Official Guidelines for Coding and Reporting, Section III.2 It would be inappropriate to query for a diagnosis that, if documented, would not satisfy this criteria. A query cannot be based solely on the information from a prior encounter. There must be relevant information within the current encounter to substantiate the query.