querxacey or not to query
I was wondering what other CDS would do in this situation. 90 year old was admitted with copd exacerbation and diabetes out of control. Pulmonary Md admitted the pt and was the attending. Pt had a complicated medical hx but no cc's or mcc's. Creatinine was 1.5 with GFR 36 on day 1. On day 3 the endocrine Md ordered a panel and the Creatinine had risen to 2.63 with GFR 21. This was not rechecked and not mentioned anywhere in the progress notes and there was no mention of renal status in the h&p. There was no order for iv fluid and the pt was discharged without a repeat Creatinine. I was worried the Md's had missed it completely but I don't think that is the purpose of a query. I did not query but was wondering if anyone else would have.
Thank you!
Melinda Scharf RN BSN CCDS
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Thank you!
Melinda Scharf RN BSN CCDS
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Comments
Katy Good, RN, BSN
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Office: 928.214.3864
Cell: 928.814.9404
Tracy M Peyton RN, CCDS
Case Management
Bradford Regional Medical Center
Upper Allegany Health Systems
116 Interstate Parkway
Bradford, PA 16701
814-558-0406
Tracey
clinically significant.
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
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
"We are dealing with Veterans, not procedures; With their problems, not
ours." --General Omar Bradley
'case-by-case: It is a bit involved as the Medical Staff 'should note
some concern for the apparent renal function' - at least in my opinion,
in order for one to query. Repeat lab testing to establish the
existence of CKD justifies code assignment for same, but in your
scenario, it is not readily apparent if a query is justified.
However, CKD, if/when noted, is one of those chronic conditions that is
always considered reportable as the condition is chronic and may have
life-long consequences impacting a patient. (The condition of CKD
always affects Medical-Decision-Making in terms of treatment options,
such as antibiotic uses, potential for nephrotoxicity, and so forth).
But, the scenario presented stating no concern was evident would make me
hesitant to query regarding the renal function. If I could not state
that a renal consult was performed, or that the condition was treated
or further specifically evaluated, I would not query.
Clinical Evaluation Defined
Clinical evaluation means the medical staff is aware of the condition
and is evaluating it in terms of evaluation, testing, consultations, and
clinical observation of the patient's condition and/or the existence of
the condition affect the types or choices of treatment rendered to the
patient.
.
Per Faye Brown, 2006, "Codes should not be assigned for conditions that
do not meet UHDDS criteria for reporting. For example, diagnostic
reports often mention such conditions such as hiatal hernia,
atelectasis, and right bundle branch block with no further mention to
indicate any relevance to the care given. Assigning a code is
inappropriate for reporting purposes unless the physician provides
documentation to support the condition's significance for the episode of
care"
Paul Evans, RHIA
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
However, if I was concerned that something was missed by the MD that could significantly impact the patient I think it is appropriate to talk to the MD about it. I would probably ask the patients nurse if the labs have been discussed and maybe ask her/him to bring it up with the MD if appropriate. I would not count that as a query though.
Katy Good, RN, BSN
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Office: 928.214.3864
Cell: 928.814.9404
if it is clinically significant. If the change is chronic and not
treated, then I agree with the no query since the patient is at
baseline. I don't feel I'm doing my due diligence for the patient if I
don't at least ask if an acute change is significant. After all, isn't
the goal a complete and accurate 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
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
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"We are dealing with Veterans, not procedures; With their problems, not
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at least see IV fluids in order to justify coding or a query for same.
But, these were pretty significant changes in Cr - odd not addressed by
MD. I would error on the side of caution on this particular case.
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
approach the situation carefully recognizing that the lack of treatment
'alone' does not preclude one from either performing a query for a
condition nor coding said condition. For instance, if a patient
presents with ICH causing 'significant midline shift' resulting in
decision to make pt Palliative, this would not preclude a CDI from
performing a query regarding the 'shift'.
If the Radiologist, for instance, stated this shift was due to edema
with Herniation of the brain, and, again, a decision was made to place
on Comfort only, then I could query for the edema or Herniation as
'shift' is not a diagnosis. However, the true severity of illness,
mechanism of death, and MEDICAL-DECISION making to place the patient on
comfort care would only be captured if I could also code the
Edema/Hernia due to the ICH.
So, while active treatment makes for an 'easy' argument to code
condition "x', consideration solely of treatment is not the only factor
to consider for CDI function or coding.
Paul
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
Katy Good, RN, BSN
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Office: 928.214.3864
Cell: 928.814.9404
Chronic Renal Failure - however, with no stated treatment for acute
renal failure, my message dealt more with the potential to capture any
apparent CKD rather than the acute component. Depending upon the
stage, CKD can be a CC or MCC and also a factor for ROM - we also know
584.9 is a also a CC affecting ROM.
Lack of treatment for ARF would be my main concern - on the other hand,
the establishment of CKD as a condition is 'always reportable' for every
encounter and 'active treatment' of CRF is not required for coding
purposes.
Paul
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
CDI Program is to strive not only for the highest degree of accuracy in
the medical record, but also to, as people with clinical background to
contribute to the highest quality of care for our patients. In the
past, we have had several cases where because we had a verbal
interaction with the MD regarding the significance of a finding, the
patient's care was enhanced and reflected in the medical record. I'm
assuming concurrent review in this case. Donna
Donna Kent, RN, BSN, CCDS
Manager, Clinical Documentation Integrity Program
Clinical Quality and Accreditation
Torrance Memorial Medical Center
ph.:310 784-6884 fax:310 784-6899
donna.kent@tmmc.com
concurrent review.
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
the record as a Permanent Part of the Record.
A 'verbal' becomes a permanent part of our record. So, I would be
cautious for medico-legal purposes in the event a 3rd party may review
the record for whatever reason.
An astute 3rd party could view this as failure to recognize and/or treat
acute renal failure. I would discuss this with the MD to whom I report
and perhaps ask him to interact with the treating/attending MD for that
reason.
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
Thanks,
Melinda Scharf RN BSN CCDS
don't think there is an absolute blueprint for this type of situation.
We would want to take a very big picture approach. However, if I was
concerned that a patient was possibly not receiving appropriate
treatment for a significant condition and had my ducks in a row, so to
speak, I would not hesitate to have a conversation with the physician.
I might consider the possibility of not entering a query in to our
system if the outcome of that conversation was not a positive one so as
not to implicate the physician.
Donna Kent, RN, BSN, CCDS
Manager, Clinical Documentation Integrity Program
Clinical Quality and Accreditation
Torrance Memorial Medical Center
ph.:310 784-6884 fax:310 784-6899
donna.kent@tmmc.com
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
In our external audits we have had numerous instances where we have been penalized for coding ARF/AKI when no treatment was rendered and we have not won those appeals.
I think it is difficult to evaluate these situations without reviewing an entire chart and seeing the pt's history, etc.
ARF/AKI is a very touchy diagnosis which is why it was removed from the MCC list and changed to a CC unless there was more specific clarification documented.
values - with the low GFR values quoted in the original, I would query
for CKD.
Paul
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