Leading Clarifications

tammy.werthtammy.werth
in CDI Talk Archive
I would like to get some feedback on the topic of leading documentation clarifications. A consulting company has informed my CDI team that since we are all RN's and part of the clinical team we do not have to be as concerned about leading clarifications as a coder would. They recommend when we perform a review that we give the provider three options: one being what we feel is the most appropriate diagnosis based on clinical indicators, treatment, and risk factors and then we also give them the option of other explanation and unable to determine. However I am having a hard time accepting this because all the literature I have researched has said to give multiple choice options and never give just one diagnosis option as that would be considered leading the provider. Do any of you just give one diagnosis option with other and unable to determine?

Thanks

Tammy



Tammy Werth
CDMP Manager, HIM Documentation Improvement
CoxHealth
Tammy.Werth@coxhealth.com
Phone: (417) 269-7040
Mobile: (417) 631-0040



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Comments

  • tpeytontpeyton
    edited April 2016
    Tammy,

    Our consulting company is the same way....I have asked numerous times about leading queries this way and told they are not because we are giving an option of other explanation and unable to determine...but would be interesting to see what others have to say.



    Tracy M Peyton RN, CCDS
    Case Management
    Bradford Regional Medical Center
    Upper Allegany Health Systems
    116 Interstate Parkway
    Bradford, PA 16701
    814-558-0406




  • sharon.colesharon.cole
    edited April 2016
    Tammy,
    Since we are querying, we have to follow the query guidelines. Just because we are nurses doesn't mean we don't have to comply.

    Sharon Cole, RN, CCDS
    Providence Health Center
    Case Management Dept
    254.751.4256
    srcole@phn-waco.org

  • dbutlerdbutler
    edited April 2016
    Tammy,

    I believe part of this perspective is also that a carefully constructed query well founded on clinical facts of the case will often only have one reasonably appropriate clinical diagnosis. However, if that was the case, I suspect the need for the CDI role would be much less?

    We provide 2 (or more) clinically appropriate diagnosis as part of a menu of options (and clinically appropriate is part of the key). Granted, there are times where it is actually difficult to come up with a reasonably clinically appropriate second diagnosis. If it really difficult, then consider a different format, like an open ended question.

    Other comments:
    First, I am concerned about this perspective. I certainly would want to know whether this approach has stood up to challenge or review by OIG, other regulatory agencies, etc. The lack of challenge does not mean there won't be one in the future. I would also engage in a lengthy conversation exploring the consultant's logic, thoughts, reference, etc. to ensure I fully understand how they build their case.

    Secondly, no matter what our professional license is, if we are engaged in activity that waddles and quacks......we need to follow the applicable guidelines for ducks (the AHIMA query brief). Ask the consulting company how they interpret the AHIMA Query guidelines when applied to coding professionals? and why should that be any different for an RN performing the query function?

    Thirdly, there certainly is room for debate with interpretation and application of GUIDELINES -- and the AHIMA brief are guidelines & not regulations (but as a cooperating party, a great deal of deference is due). As an example, one of the areas of debate that I commonly see is the bit about introducing a new diagnosis. I am comfortable with introducing the term 'anemia' as part of an ABLA query menu option when anemia is not yet documented. However, it is not part of the body of the query, and there are other clinically reasonable diagnostic options. This approach to queries may be similar.

    Finally, look at the AHIMA CDI Tool kit & Guidance in addition to the Query Brief. Additionally, there is an interesting piece from the CDI e-mail newsletter that helps to provide some background, commentary and insight: http://www.hcpro.com/acdis/details.cfm?topic=WS_ACD_STG&content_id=250910 (May 13, 2010).

    You may (or may not) want to take a look at a recent post: http://blogs.hcpro.com/acdis/2012/01/thoughts-on-evaluating-vendorsconsultants/ -- warning, a bit of self promotion :)

    Bottom line for me -- I celebrate and enjoy solid discussions that explore possibilities and seek to raise the professionalism, ethics, skills & knowledge of our profession, so this type of string is one I view with a great deal of excitement!

    Don



    Donald A. Butler, RN, BSN
    Manager, Clinical Documentation
    Vidant Medical Center, Greenville NC
    DButler@vidanthealth.com ( mailto:mDButler@vidanthealth.com )


  • vdavis2vdavis2
    edited April 2016
    I am with Don on this one!!! If you are functioning in a role of the CDI Culture... quack, quack- You are a DUCK for all general purposes! If you are functioning as a nurse, a case manager, or anything else you would have different guidelines that were acceptable standards of practice under each role. I wouldn't go out to the nursing unit and administer IV Morphine for a patient that is in pain and calling out for pain meds even though the pt may have an active order for the medication-but I would find the nurse and have a discussion about how the pt was doubled over in pain and requested pain meds. For me, the verbal interaction with an MD crucial! Clinically you can express all of those nursing tidbits/observations, but the MD can still form his/her own opinion and document it accordingly!

    In a formal query, I would give several clinically based options (first one listed being my most obvious clue ;).
    To give the "unable to determine" choice, I go a step further... I have found that just "unable to determine" is self limiting and not thought provoking for the MD.

    Example: If I were asking about the etiology of the patient's CP, I would use this as my unable to determine choice: "Unable to suspect or determine the cause pt's CP."

    This is a good reminder for the MD on the inpatient side to use "possible, probably, likely, suspect, etc.," if applicable. I also restate the item I am seeking clarification about (CP) in order to remind the MD to think about what he/she "can't determine." This really does work!!! The MD quickly thinks, "Can I really not suspect a cause of the pt's chest pain."

    Then my last choice "Other (please specify):" ... usually we don't have too many unable to determine answers. :)

    Vicki :)



    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

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    You provide an Excellent tip regarding response = "unable to
    determine" - should provoke MD thought prior to just checking a box.



    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

  • vdavis2vdavis2
    edited April 2016
    MD to pt: "I am sorry SIR! You are dying from Unable to determine. I can't suspect, treat, rule out, or think of anything that could be causing you to die! Good Luck with that!"

    Go ahead and prepare for an automatic drop in patient satisfaction scores!!! (and graciously anticipate the denial for payment!!!)

    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


  • lspryszaklspryszak
    edited April 2016
    When I teach the query module in the CDI Boot Camp I receive questions like yours from every class. What I tell students is this: "if someone tells you that it's okay to do something that is not covered in the Official Coding Guidelines, Coding Clinic, the AHIMA query briefs or your policies - then it is your duty to ask them for their reference sources and citations to back up what they are telling you it is okay to do." In other words - PROVE it.

    As someone who has been a CDS for over 10 years, of course I have personal opinions about what I think I should be able to do - but that doesn't make it "right" and I do not want anyone in my classes to go back and implement practices based on my "opinion".

    I also point out that most consulting companies include a "hold harmless" or similar clause in their contracts - in other words, they are not liable for the actions of the CDS and/or coders or how things are done after they leave. So it's pretty easy to give opinions if you're not responsible for any potential fallout.

    I also point out that if a facility becomes engaged in a lawsuit or investigation where the focus involves physician queries (and there have been 2 major government investigations to date, both of which resulted in penalties to the hospital system), the consultant is not going to "write the check" to the government to pay your fines. Also consider that if you ever become the subject of such an investigation, your facility may have to operate under increased scrutiny of its practices for several months or even years, depending on the situation.

    I recommend that if a consultant tells you it's okay to do something then, make sure you get it in WRITING! This document should clearly cite whatever references they are using as "expert authority". The laws concerning liability of consultants has changed and they MAY be liable for their actions if an investigation or lawsuit is raised. It would then be crucial for your organization to be able to proved that you were following the advice of an outside consultant.

    Even if you're new to this CDI role, you should always ask "where does it say that"? or "where does that information come from"? Many things that we are taught by others comes from the "that's the way we always did it" school. If you're the one who has to do the job and be held responsible for your actions, it just makes sense to have the comfort of a document that says you're doing the right thing.

    At least, that's my two cents. It's not a question of whether I'm a nurse or a coder, it's a question of acknowledging the documents that have been published. If this consultant wants to have CMS review and approve their advice, and if CMS publishes this advice as best practice for the rest of us, then I'm all for it.
  • tammy.werthtammy.werth
    edited April 2016
    I want to thank everyone for the feedback regarding leading clarifications as well as the links, they were very helpful. This discussion has spurred many questions for the consulting company. This has also helped my research in finding the best format for our clarifications and confirm my understanding that no matter what a consulting company recommends we as an institution have to decide what format is most appropriate to meet the needs of our program.

    Thank you all so much!

    Tammy



    Tammy Werth
    CDMP Manager, HIM Documentation Improvement
    CoxHealth
    Tammy.Werth@coxhealth.com
    Phone: (417) 269-7040
    Mobile: (417) 631-0040



  • kathryn.goodkathryn.good
    edited April 2016
    I can see both of these being problematic. I think you are doing a good job summarizing the case and presenting the clinical indicators. Format-wise, you may find that your providers prefer simple bullet points for a quicker/easier read. That seems to be somewhat provider specific. Some prefer a narrative and others prefer bullets. We generally use bullets but I will modify for a narrative approach when the query is unusual/complex and I feel a narrative style query will be more effective at presenting the case. I think where you are running into trouble is the formatting of your question. The question should be open-ended, not leading them in a particular way. You cannot directly ask if the patient has a particular condition (barring specific circumstances). You can ask them to clarify an existing condition with additional specificity or you can ask what condition is being treated. It is appropriate to provide options but you must include all reasonable options plus 'other' and 'unable to determine'.

    For the first query, I would include the clinical indicators you used (making sure to include where in the record you are finding them), Then I would just ask if they can further specify the malnutrition as: Mild, Moderate, Severe, Other, Unable to determine

    For the 2nd query, you cannot directly ask the provider if the patient has a particular dx. That is introducing a new dx to the medical record and leading. Your clinical indicators are there but an open-ended question would be (for ex):

    Can you please clarify whether the patient is being evaluation/treated for: Acute respiratory failure, Chronic respiratory failure, Acute on chronic respiratory failure, Other, Unable to determine


    Hope that helps,

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


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