Query as only documentation of dx/retrospective query

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
I have a couple questions.

I am wondering if any of you have come accross issues when coding dx that are ONLY documented on a query but are not carried over into progress notes and/or D/C summery. Our queries are a part of the permanent record and our coders do code based on queries alone (though we encourage MD's to carry through into progress notes).

Also, do your CDI's query retrospecitively for missing dx (IE, pt on vent with no Resp Failure dx, only distress documented)? If so, have you seen any problems with this? For example, I review all death charts prior to finalization of coding for documentation and will query if it would impact DRG, SOI or ROM.

These questions are being posed by MD's and I want to make sure I am providing the correct answers.

Thanks,
Katy

Comments

  • Unknown
    edited May 2016
    Our coders will code from a query (a permanent part of the record), and yes, sometimes that is the only place a diagnosis is documented.

    I review all mortality records which do not have a SOI/ROM of 4/4 - the coder returns the chart to me before final billing. I then look for opportunities to query for SOI/ROM.

    Our coding manager has also given me some very old records (9 months old) to review which she was auditing which retrospective queries were placed for complete documentation. At that late date one cannot do a rebill but one would get accurate documentation.

    Charlene
  • sharon.colesharon.cole
    edited May 2016
    Our queries are not a permanent part of the medical record, so the physician must document in the progress notes and/or DC summary.

    Sharon Cole, RN, CCDS
    Providence Health Center
    Case Management Dept
    254.751.4256
    srcole@phn-waco.org
  • tpeytontpeyton
    edited May 2016
    Our clarifications also are not part of the permanent medical record, therefore if the physician has to document in progress notes and dcs.

    Tracy M Peyton RN, CCDS
    Case Management
    Bradford Regional Medical Center
    Upper Allegany Health Systems
    116 Interstate Parkway
    Bradford, PA 16701
    814-558-0406
  • robert.hodges2robert.hodges2
    What Sharon and Tracy said. The provider must document the response in the medical record.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
  • vdavis2vdavis2
    edited May 2016
    -Our queries are part of the legal record
    -We query concurrently if possible. We expect for the answers to end up in the progress notes as soon as possible. (And of course we want the info to be carried into the d/c summary.)
    -We may go back and ask for an addendum to a discharge summary if the diagnoses were dropped or if it lost specificity in the dc summary.
    (ie: sepsis with link to infection).

    -Our CDI program reviews concurrent records, however we will review and assist with any documentation needs identified. (querying, discussions with MD's, review for opinions, write appeal letters, assist on complex cases to identify opportunities to improve the GLOS, process improvements for outlier cases, assist with reviewing documentation submitted to surveyors, drill downs for core measures-anything that helps the accuracy and quality of the documentation in our hospital.)

    :) V


    Vicki S. Davis, RN CDS
    Clinical Documentation Improvement Manager
    Health Information Management Department
    Alamance Regional Medical Center
    Office (336) 586-3765
    Ascom Mobile (336) 586-4191
    Fax (336) 538-7428
    vdavis2@armc.com

    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
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