Retro query documentation

kimberly.strand

Would appreciate your thoughts on the following: The admitting physician documents Sepsis due to pneumonia in H&P and one follow-up progress note. A different hospitalist rotates in for the medical care of the patient & never mentions either in his progress note or DC summary. A retro query is submitted to the admitting physician in which he responds that "yes" both Sepsis & pneumonia were present and treated at the time of admission. Would you feel comfortable in coding both conditions after the initial clarification or would you require further retro query of the physician who did not mention the conditions?

I am being asked by coding to submit another query for clarification of the two conditions. Should I have queried the attending or the discharging physician for the information or does it matter?

THanks so much! Kimberly

dvitalone1

I feel that as long as there are clinical indicators to substantiate the 2 diagnoses then a further query is not necessary

robert.hodges2

I probably would have queried the second hospitalist since they are the ones with the different diagnosis and would have queried based on the lack of consistency in documentation. Kind of a Dr A documented pneumonia and sepsis on date x and y. Your notes do not address these conditions. Are these conditions still active or appropriate?

Just my thoughts.

Robert

Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
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kimberly.strand

Thank you... yes, both conditions received eval, treatment and monitoring thru the stay. Thanks Robert I can see your point! It's often when I query the second or discharging physician they want me to ask the admitting. Round robin thing. Appreciate your thoughts. ~ Kimberly~

robert.hodges2

Yea, the round robin is always fun. Good luck

Robert
 
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Unknown

A further query is not necessary


Tracey

evanspx@sutterhealth.org

As multiple possible conditions may be listed early in the course of
treatment as differential diagnoses, but not confirmed, a query would be
prudent.

One may often see Sepsis (and many other processes) documented early in
the course of admission but 'after study, the conditions are not further
declared. Our discussions with our Medical Staff and the individual
physicians when we round and review charts indicates that sepsis may be
in the mix early on, but is sometimes ruled out with the abnormal signs
and symptoms attributed to some other process. I have reviewed cases
from 3rd parties (RAC) disallowing the final coding of conditions that
are not clearly and consistently documented and confirmed in a 'final
diagnostic statement).

The concept applies to issues other than sepsis, such as PNA, AMI, etc.


Paul Evans, RHIA, CCS, CCS-P
Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739

kimberly.strand

Thank you Paul. I do understand what you are saying. DRG validation chart request are being sent out to many 3rd party insurance providers. It confuses me though when it is prudent to have the final diagnosis stated in the DC summary for just that reason, our coding department does not always wait for the DC summary to final code. What are your thoughts on that if you don't mind.

catladyrn

I think that the query to the admitting physician was unnecessary, as all he could do was reiterate what was in his H/P. The question becomes whether it was dropped as a diagnosis or ruled out, and that could only be answered by the second physician. I do send queries like that, when it's not clear from the documentation or the clinicals what happened to a diagnosis that disappears. I keep trying to teach our physicians not to drop a diagnosis, but to document whether it's ruled in, ruled out, remains possible, or was changed to something else. That will save a lot of queries.

Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center

Unknown

She did query and got a response

Tracey

evanspx@sutterhealth.org

No, I don't mind at all. This is all very complicated, and beyond what
we can discuss in a deserving manner via e-mail. I think one of our
vexing issues may be different interpretations of what qualifies as
'clear and consistent' documentation allowing us to report our cases
accurately, Coding Clinic has written a lot about this. In my mind,
the RAC (and others) take a draconian stance in this regard, and I feel
they may 'deny' conditions that most reasonable people would agree were
present.

However, JCAHO and probably your medical staff by-laws also say
something to the effect that the final diagnostic statement and/or
summary should document all significant conditions. Sometimes 3rd
parties will use absence of a condition as a basis for disallowing a
code.

Some people use the AHIMA Practice Brief as a model for compliance, and
this states, in part:

AHIMA Practice Brief
Queries as a Tool for Clinical Documentation Improvement
May 12, 2008
PART I

4. Consistent: When a patient's record demonstrates inconsistency
such as disagreement between two or more treating physicians with
respect to a diagnosis, then a query may be appropriate. Example of
inconsistent: The attending physician states renal insufficiency and the
renal consultant documents acute renal failure

Some people may interpret this to mean if Sepsis is stated a few times
in the record, but not further noted or confirmed by the attending as a
final condition, it may not be coded. Personally, I feel this may be a
bit restrictive...but this document is accepted as a Best Practice.

From my point of view, I am comfortable coding a record w/o the summary
if I am 'reasonably certain' my MS-DRG is correct. The coding staff
is under a lot of pressure to drop bills...if a summary later does not
support final assigned codes, I feel management would need to take this
into account if I am directed to final code w/o a summary.



Paul Evans, RHIA, CCS, CCS-P
Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739

kimberly.strand

Paul, Thank you for your time and opinion as it is mindful information. I get what you are saying and it is muddy waters at times. There are so many different opinions and guideline interpretations but are helpful in some way. Again, your time in answering my query is much appreciated!

Kimberly

kimberly.strand

Renee, thank you for your response. I agree totally about a dropped diagnosis and follow-up with a query for "rule-in" "ruled-out" and that was why I queried in the first place concurrently. Unfortunately the patient discharged that night with an unanswered query & it became a retro for me to send. My thought was to query the author of the diagnosis as so frequently I am directed that way from coding. I see your point totally and next time it will go to the discharging physician. In our facility we have so many hospitalist who rotate in one day and out the next which creates a mess for consistent documentation and "Problem list" accuracy. I mostly get these answered concurrently but some like this one required post dc follow-up. Physicians really try to pass the buck when it comes to queries. So many opinions from the coders, but I agree with your thought for the future.

Thanks again for your time. ~ Kimberly~

evanspx@sutterhealth.org

Kimberly...well-stated and we face the same issue here - many teams
caring for the patient, and sometimes the summary may lack some details.
One thing I have realized may be of benefit is to ask for confirmation
of key terms as I review concurrently...."the note states XXXX on date
XXXX, and this is not further stated as a differential ruled out or
confirmed - can you please confirm if the condition of XXXX was present,
treated, and has resolved, or can you indicate if this was ruled out?"

Sometimes this helps - I think a degree of subjectivity is impossible
to eliminate in coding.



Paul Evans, RHIA, CCS, CCS-P
Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739

sbeatty

Initially in your post, you mention the admitting physician as the initial documentor of the diagnoses. Was he/she determined to be the attending MD, as you asked in reference to the RQ opportunity? The rules say the attending is the one who's documentation takes precedence. If the admitting was determined to be the attending MD, I'd say no RQ is required. If the discharging MD is determined to be the attending, I would suggest that a RQ is in order. It all depends on your organization's procedure for assigning attending MD status. IMO...