leading queries

ruth_pfrengle

We are going to have our queries as part of the permanent medical record with the clarification of a diagnosis, options to select other diagnoses and an option to maintain the current documentation---is this considered leading?

Ruth Pfrengle, RN, BSN
University of Rochester
Utilization Management Department
Clinical Documentation Manager
601 Elmwood Avenue Box 322
Rochester, New York 14642

Phone: 585-273-3816
Pager: 585-275-1616 ID 2088
Fax: 585-276-2801

robert.hodges2

My understanding is that as long as the provider is given options to
choose from then it is not leading. All my paper forms and verbal
requests include "other" as well just to keep the field open.



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



"Anyone who has never made a mistake has never tried anything new."
-Albert Einstein

bea.smith

I would also make sure you have an option of "unable to determine",
which I guess is similar to your "maintain current documentation". We
used to keep our queries on the charts but one of our queries was found
leading because we didn't include unable to determine. We've revised all
queries now, but our leadership team still decided it was best we not
have queries part of the chart. It makes it much harder on CDIP.

epracz

Also, you cannot ask yes or no questions unless it is only about POA. You can

tiffany_susan

Ruth,
We recently looked into making our clarifications a permeant part of the
medical record and are still undecided. Would you be able to share what
factors made you decide to keep the clarifications? Any info you would be
willing to share would help me a lot!

Thank you,
Susan Tiffany RN, CDS
Supervisor
Clinical Documentation Program
Robert Packer Hospital & Corning Hospital
570-882-6094 pager 465
Fax 570-882-6768
Tiffany_Susan@guthrie.org

dog

My understanding is that a nurse CDS is not held to the same query rules as a coder CDS, i.e., AHIMA. Because we are clinically based, we are allowed to consult with the physician regarding possible diagnoses. We are allowed (and expected) to analyze the data and make judgments based on our nursing knowledge, including potential diagnoses that have not already been introduced into the chart.

My queries are scanned into the record, but if an outside auditor requests the chart, my query is not reproduced for their review.

Renee

Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital

mannb1

At our hospital, we were trained by Navigant Consulting. According to their training & recommendations, there is "no different standard" for querying process based on the fact that we are nurses. I believe that J.A. Thomas allows their CDS more leeway - as you say, based on clinical expertise, but, according to our consultants, as nurses we are held to the same query regulations/practices as professional coders. If anyone has something that is published from AHIMA or CMS that states differently, please do share.

I think this could be a slippery slope?

dbutler

It certainly can be a slippery slope......seems to me that there is not a single standard currently present.
Per the blog post ( http://blogs.hcpro.com/acdis/2010/03/good-gossip-ahima-readies-to-release-new-query-brief/ ) very recently -- sounds like there will be more from AHIMA with their CDI working group.

My own perspective is that there likely is a bit more leeway for the concurrent role (whether RN or Coding Professional), but we must be careful......whether one releases the query or not, we SHOULD be comfortable if queries were to be released.

There are motivators for consulting companies that don't 100% line up with the interests of one's own hospital (maybe 98%+) so I tend to listen to everything with a grain of salt.

As far as I know, there has been nothing specifically published to date for CDI query guidelines.

Don

robert.hodges2

The closest thing out there is the AHIMA practice brief on queries. That's what I used as my reference when making my policy.

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602

sbeatty

Can you feel comfortable going to court and defending your analysis of
the monitoring, evaluation and/or treatment that indicated a diagnosis,
and did you give the physician other options, i.e. No further
documentation is needed, Not a reportable condition (definition
provided), or Other diagnosis documented. We haven't included Unable to
determine-yet!

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meet your needs. Please complete a satisfaction survey for our
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Sandy Beatty, RN, BSN, C-CDI
Clinical Documentation Specialist
Columbus Regional Hospital
Columbus, IN
(812) 376-5652
sbeatty@crh.org

"Obstacles are those frightful things you see when you take your eyes
off the goal." Hannah More

dog

Since nothing that I do is part of the record or used to guide the treatment plan, I view my queries the same as if I were to ask the same question without it being put on paper. And there's nothing in the nurse practice act that says I can't ask a doctor a question. The paper query only serves two purposes: asks the question when the physician is not available directly, and allows other people (spelled supervisors and consultants) to see what I've done and monitor my productivity.

I don't feel bound by AHIMA any more than a coder is bound by the American Association of Critical-Care Nurses. I consider them guidelines, not rules, for nurses. Do I have an official reference for my opinion? No. The nurse CDS role is evolving and the standards are not set. Y'all certainly have the right to disagree.

Renee

Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital

epracz

It depends who you ask and make sure to check with your compliance department. Yes, you would think that as a CDS you would be able to do this but there is no policy/brief addressing how a nurse/CDI can query. We were trained 5yrs ago from a consultant and use to query using our nursing judgment. Then we changed using the multiple choice format giving options when this was first introduce at the ACDIS 2nd conference (Wasn't aware you still couldn't introduce a diagnosis (even if you had the clinical and treatment because this is considered leading). Recently, we had a very long discussion about this after going to the HCPRO CDS workshop and finding that ACDIS adheres to the AHIMA brief. Our compliance department decided that we should follow the AHIMA guidelines. I was told that ACDIS is addressing this at the June conference with an update. I am also being told that AHIMA has a CDI task force working to develop standards and/or guidelines for those acting as CDS. There are some ACDIS members serving on some of the committees representing the CDS viewpoint. So the bottom line each facility needs to determine what is considered compliant for THEIR organizations and then monitor and audit for compliance. This has become a very hot topic especially since everyone is concern about RAC. Also, was told that the consultant was not legally or financially responsible if a facility is audited and found accountable for violations based on the advice of that a nurse can be more direct because your clinical.

tiffany_susan

Extremely slippery! I did just read a blog on the ACDIS website about a
possible release from AHIMA specifically for CDS"s

Thank you,
Susan Tiffany RN, CDS
Supervisor
Clinical Documentation Program
Robert Packer Hospital & Corning Hospital
570-882-6094 pager 465
Fax 570-882-6768
Tiffany_Susan@guthrie.org

arobinso

What about Physician advisors?

ctrygar

Renee

I have been a CDI nurse for a little over two years and when it comes to leading queries that has always been a concern of mine. I see by reading all the emails there still seems to be some difficulty in defining leading queries.. However you mentioned in your email about not being allowed to introduce new diagnosis in the query.
Could anyone help me with this one. In the AHIMA Managing an effective query there is an example of a query listing different types of resp failure with a patient who has copd with chronic o2 . This to me sounds like introducing a new diagnosis in to the chart.. I use their query example when querying for chronic or acute resp failure. I also have a query for acute blood loss anemia where i list different types of anemia's, other and unable to determine. Would this be considered introducing a diagnosis into the chart when the physician doesnt document anemia. If anyone has a comment i would appreciate help..

thank you

cheri

mannb1

For anemia that is not specifically stated by the MD, we have an abnormal lab/tests query that we can write in the clinical data, and then give the MD the options of the anemias, other, unable to determine, etc., so that way we aren't the first to state "anemia".

For the resp failure, we have a "blank" documentation clarification form w/room for the pt's current dx, treatment, and the clinical findings, on which we can list the possibles: acute resp failure, chronic resp failure, etc., other, unable to determine. We do have a new "blanket" respiratory query, but it does list the Acute resp failure, so I think we need to be careful using that one, if the resp failure isn't already on the table by someone's documentation.

Hope that makes sense?

robert.hodges2

Cheri,

I think the secret, at least as it was explained to me, is to offer choice. You can't ask a provider something like "the renal functions meet criteria for acute failure under the RIFLE criteria, is that what they have?" You have to say, "Are you able to evaluate the patients renal functions and indicate if they have acute renal failure, acute renal insufficiency, or something else that is causing the lab values to change along with the clinical significance of those values?"

I hope this makes some kind of sense. I know I ask these types of questions all the time, especially if I see the acute change in lab values and some type of clinical symptom or treatment that is related. It usually does end up resulting in a new diagnosis being added to the record.

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
 
"Anyone who has never made a mistake has never tried anything new." -Albert Einstein 

"This email is intended only for the use of the person or office to which it is addressed and may contain information that is privileged, confidential, or protected by law. All others are hereby notified that the receipt of this email does not waive any applicable privilege or exemption for disclosure and that any dissemination, distribution, or copying of this communication is prohibited. If you have received this email in error, please notify this office immediately at the telephone number listed above."

epracz

Do you query them to document with clinical from the abnormal/lab test query and wait till they state anemia then send out another query for the specific type? If you are documenting the choices of anemia and anemia is not written then that is introducing a diagnosis.

epracz

This is a very good question because looking at the example for COPD, this to me is introducing a new diagnosis and we were told you cannot do that. We need someone from ACDIS/ AHIMA board explain this one. If you can do this then why do you need anemia documented before you can give choices if the clinical supports what you are looking for?

epracz

This is not what was taught at the CDS Boot camp. They focus on not introducing new diagnoses. EX.. Send query for abnormal findings then when they document anemia then re-query for specific type of anemia.

I agree with what you are saying below.

ctrygar

that is the confusing part because the example AHIMA gives in their managing an effective query gives an example that introduces a new diagnosis to the query process

nbrunson84

If there are clinical indicators of a diagnosis being treated - I would
Query. You are not "introducing" a diagnosis if you are treating it
already. You are simply asking for medical necessity.

Now if there was something on an XRay or CT and the Dr. wasn't actively
treating it - then I would not Query for it. I might verbally ask him
if he had seen the XRay or CT - "Is that significant?" and go from
there.



N. Brunson, RHIA
Clinical Documentation Specialist
Bay Medical Center

deanne_wilk

I run into this all the time. Coders code a lot of times to prevent being audited. The practice brief clearly states your query is compliant. ACDIS also has a followup to the AHIMA to further substantiate. Instead of using Unable to Determine i use Unknown with my Other. CDI is in place to review for clinically relevant diagnosis that may not be documented which is why we need to know clinical indicators. I would review brief with the Director.
Sent from my iPhone

annnd2009@gmail.com

I like you solution on unable to determine. Just thought of another "phrasing"

Other, or unknown (if able, specify reason)___________

Sent from my iPhone

lmcnamara@cortlandregional.org

We are fortunate to have paper queries and they do become part of the medical record. (attached) I believe that this is one I would use in your scenario. (and I have on many occasions when there is lack of documentation). There are more options, so as not to "limit" the physicians. I believe that as CDI's we are able to look at vital signs, labs, diagnostic work up and query for proper diagnosis if they are not documented by the physician/practitioner. It all supports SOI/ROM and patient care/treatment and quality.

Remember that to code and capture acute respiratory failure ---- if on vent or bi-pap, OR and 2 of 3 of, pCO2 ->50, pO2 On Oct 17, 2014, at 7:35 AM, CDI Talk wrote:

lmcnamara@cortlandregional.org

We are fortunate to have paper queries and they do become part of the medical record. (attached) I believe that this is one I would use in your scenario. (and I have on many occasions when there is lack of documentation). There are more options, so as not to "limit" the physicians. I believe that as CDI's we are able to look at vital signs, labs, diagnostic work up and query for proper diagnosis if they are not documented by the physician/practitioner. It all supports SOI/ROM and patient care/treatment and quality.

Remember that to code and capture acute respiratory failure ---- if on vent or bi-pap, OR and 2 of 3 of, pCO2 ->50, pO2

annnd2009@gmail.com

Hi

Is the 2 of 3 your facilities definition? My understanding is paO2 of less than 60 which is equivalent to 90 O2 sat on ra I think I read 81% on ra would be 46% well below the criteria of 60%. They only stated 4L which equals supplemental O2 of 36%. Cheryl Ericsson stated they like to see 40 and this is in Cdi pocket guide. My thought was EVEN with 36% they were only 89%. So did they need more that they didn't get to bring them to an acceptable saturation? Or did they have an undocumented copd -which made them safer at a lower saturation than to knock out their respiratory drive.

Regardless I do see where at the very least initially the criteria might be questioned. I think it's supported but understand where a discussion and other clinical expert might need to weigh in.

I didn't lust chronic because leading states clinically supported by record I can only justify ACUTE based on no recorded respiratory history. The brief stated there may be only one clinically relevant choice. This is why I felt acute or not present were the reasonable options.

Thank you for sharing, while I may have a different opinion itakes me have to reevaluate "what is obvious to me" is actually a little gray and may require more expert input.

Which is what you all are for!!!