I am looking to find information on HCFA criteria. We recently got a denial and the company used this criteria for ac resp failure. Does anyone know where I can find this criteria?
Thank you but this looks like only for home dme's....this was an in patient that they used these guidelines on for a denial. Or am I missing something?
Tracy M Peyton RN, CCDS Bradford Regional Medical Center Upper Allegany Health Systems 116 Interstate Parkway Bradford, PA 16701 814-558-0406
This is an old citation from Medicare, going back years, that relates to chronic respiratory failure and the provisions of home oxygen. No relatikonship to acute respiratory failure. May I suggest you ask the company intiating the denial to substaniate the rationale for using an old CMS publication, pre CMS, to deny a claim. Sounds like this organization is on a fishing expedition.
Was this an acute inpatient admission, did it meet InterQual or Milliman criteria? What agency issued the denial? I suggest asking them to provide a specific reference or a copy of the criteria they used.
Vanessa Falkoff, RN Clinical Documentation Coordinator University Medical Center of Southern Nevada office (702) 383-7322 cell (702) 204-0054 vanessa.falkoff@umcsn.com
Thank you for posting this question, because it made our team more conscience about the resources referenced by review companies. We have a DRG denial based on "Industry Standards" as noted by outdated AHIMA Practice Briefs "Developing a Physician Query Process" and "Queries as a Tool for Clinical Documentation." However, "Managing an Effective Query Process" updates the cumbersome 2001 Practice Brief "Developing a Physician Query Process."
The company stated they would not pay for DRG 871 because our concurrent query (just after admission) was "leading." The company sited that "Open ended questions that allow the physician to document the specific diagnosis are Preferable to multiple choice questions..." Our question listed clinical indicators and documentation related to SIRS (including the MD notations of Left Shift in the CBC). We gave multiple choice answers: "SIRS, SIRS due to Infection, Sepsis, Unable to determine, or Other" Our electronic documentation clarification forms also have a disclaimer that states "Please exercise your independent, professional judgment when responding. A specific answer is not anticipated or expected. In your clinical opinion..." The multiple choice answers were reasonable based on the clinical indicators. The COPD query example used in "Managing an Effective Query Process" is very similar to our query.
Anyone have any thoughts or similar situations? We have appealed the denial.
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
You described what seems to be a compliant query- I am glad you are appealing and it may be helpful to our group to know the outcome of this appeal. The wording you are using 'sounds very' similar to what I have seen touted as compliant and our industry-standard. So, I hope you are successful - I do believe some of the 3rd parties that deny our claims are sometimes subjective given there is not exact agreement regarding what constitutes a 'leading' query.
Open-ended questions may be 'preferable' to some, but are they mandatory - are they EFFECTIVE? I feel they may not be effective because the response for instance, for a query for 'urosepsis' that is open-ended and does not offer a definition of SIRS and a choice for "UTI with SIRS" with a choice for 'only UTI', plus the standard response, "unable to determine' or 'no infection present' often results in the response: "I said Urosepsis".
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 evanspx@sutterhealth.org
I agree. Your query sounds good to me. That being said, when I formulate our query templates I always try to include a diagnosis that would NOT yield a CC/MCC or DRG change. I know this is not required (at least I have not seen that it is) however, I feel it is an extra step I can take to ensure that is does not appear to be "leading".
For example, our Sepsis/SIRS query list clinical indicators and then includes check boxes with options for. "Localized Infection", "SIRS", "SEPSIS" and "Septic Shock" as well as the obligatory "Other" and "unable to determine". When I have positive blood cultures I often change the localized infections option to "bacteremia".
I'll be interested to hear what happens with this one. There is so little guidance as to what is/is not ethical/legal in regards to queries, I am constantly second guessing myself as to what is appropriate.
Good Luck!
Katy Good, RN, BSN Clinical Documentation Program Coordinator AHIMA Approved ICD-10CM/PCS Trainer Flagstaff Medical Center Kathryn.Good@nahealth.com Office: 928.214.3864 Cell: 928.814.9404
I attached a query for HIV with several responses for the Clinician. Unable to Determine and Disagree are two of the choices...we have this choice on all of our forms...any suggestions for improvement greatly appreciated.
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 evanspx@sutterhealth.org
Paul, I agree that in cases like this there is not much else you can offer. I have queries like this too. For Example, if anemia is already documented in the record, I have a query which asks for the type/etiology and provides check boxes with types as well as "other" and "unable to determine". But, if I was query for anemia itself, with no documentation of the condition at all but maybe just decreased H/H and documented blood transfusion, I would not have the same check boxes, I would include additional options like "hemodilution" or maybe other hematological conditions. In this instance I would design my query as you did.
Sorry I don't have any brilliant ideas,
Katy Good, RN, BSN Clinical Documentation Program Coordinator AHIMA Approved ICD-10CM/PCS Trainer Flagstaff Medical Center Kathryn.Good@nahealth.com Office: 928.214.3864 Cell: 928.814.9404
We appear to have the same software as you do. We have received denials and have appealed them all and won. Our criteria, by diagnosis, for querying was approved by the medical staff quality committee as an appropriate reason to query, and the criteria we use are from recent clinical research that the physicans reviewed, accepted as appropriate, and approved. Since we have the approval of our physicians that this is appropriate clarification behavior, and our software generates the query verbiage except for the actual criteria we are using WITH THE SOURCE CITED, we believe we have a compliant query process. This is substantiated by independently contracted HI auditors who audit our codng and querying annually. Don't be intimidated by these people-appeal, appeal, appeal!!
We incorporate 'evidence-based' criteria into the development of our query forms....for instance, we use the criteria published in 2008 Surviving Sepsis The Medical Staff endorsed the criteria and reviewed each query form .
I believe this helps a facility to define, document and defend coding decisions and I concur with the previous statement regarding the use of accepted criteria in a query form. If the chart does NOT meet baseline criteria for a query for a particular topic, a query will not be performed by a CDS for that topic.
I do not believe all of the various 3rd parties 'know' or acknowledge all of the most recent definitions (Acute Kidney Injury) for key conditions. This, plus a demonstrated lack of knowledge or regard for some of the basic principles of coding as stated in the denial notifications leads me to believe we should appeal vigorously any and all cases where it is reasonable to do so.
Paul Evans, RHIA, CCS, CCS-)
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 evanspx@sutterhealth.org
In general, I liked the original query as described. It had a several excellent elements.
I agree with Paul & the original poster, a query is NOT leading when reasonable clinical options are presented in a multiple choice format. Open ended questions for most are not as effective.
HOWEVER, I would be more comfortable with the original posted example if there were at least one option offerred that would have ended somewhere other than sepsis DRG (SIRS, SIRS d/t infections, Sepsis are what were stated). A better format would be to include one additional option of "pneumonia (or whatever the infectious process existed in this case) without SIRS or Sepsis".
One other point, was the admission AFTER the release of the current AHIMA Query practice brief? The applicable guidance would be that which was in effect at the time of the admit.
Comments
Tracey
Tracy M Peyton RN, CCDS
Bradford Regional Medical Center
Upper Allegany Health Systems
116 Interstate Parkway
Bradford, PA 16701
814-558-0406
Tracy M Peyton RN, CCDS
Bradford Regional Medical Center
Upper Allegany Health Systems
116 Interstate Parkway
Bradford, PA 16701
814-558-0406
Diane Draize RN, CPUR,CCDS
Clinical Documentation Specialist
Ministry Door County Medical Center
diane.draize@ministryhealth.org
920-743-5566 ex 3143
We earn trust by working together as One Ministry to keep PATIENTS FIRST in everything we do
Tracy M Peyton RN, CCDS
Bradford Regional Medical Center
Upper Allegany Health Systems
116 Interstate Parkway
Bradford, PA 16701
814-558-0406
Was this an acute inpatient admission, did it meet InterQual or Milliman
criteria?
What agency issued the denial? I suggest asking them to provide a
specific reference or a copy of the criteria they used.
Vanessa Falkoff, RN
Clinical Documentation Coordinator
University Medical Center of Southern Nevada
office (702) 383-7322
cell (702) 204-0054
vanessa.falkoff@umcsn.com
Tracy M Peyton RN, CCDS
Bradford Regional Medical Center
Upper Allegany Health Systems
116 Interstate Parkway
Bradford, PA 16701
814-558-0406
The company stated they would not pay for DRG 871 because our concurrent query (just after admission) was "leading." The company sited that "Open ended questions that allow the physician to document the specific diagnosis are Preferable to multiple choice questions..." Our question listed clinical indicators and documentation related to SIRS (including the MD notations of Left Shift in the CBC). We gave multiple choice answers: "SIRS, SIRS due to Infection, Sepsis, Unable to determine, or Other" Our electronic documentation clarification forms also have a disclaimer that states "Please exercise your independent, professional judgment when responding. A specific answer is not anticipated or expected. In your clinical opinion..." The multiple choice answers were reasonable based on the clinical indicators. The COPD query example used in "Managing an Effective Query Process" is very similar to our query.
Anyone have any thoughts or similar situations? We have appealed the denial.
Thanks,
V
Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
ARMC
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
appealing and it may be helpful to our group to know the outcome of this
appeal. The wording you are using 'sounds very' similar to what I have
seen touted as compliant and our industry-standard. So, I hope you are
successful - I do believe some of the 3rd parties that deny our claims
are sometimes subjective given there is not exact agreement regarding
what constitutes a 'leading' query.
Open-ended questions may be 'preferable' to some, but are they
mandatory - are they EFFECTIVE? I feel they may not be effective
because the response for instance, for a query for 'urosepsis' that is
open-ended and does not offer a definition of SIRS and a choice for "UTI
with SIRS" with a choice for 'only UTI', plus the standard response,
"unable to determine' or 'no infection present' often results in the
response: "I said Urosepsis".
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
evanspx@sutterhealth.org
For example, our Sepsis/SIRS query list clinical indicators and then includes check boxes with options for. "Localized Infection", "SIRS", "SEPSIS" and "Septic Shock" as well as the obligatory "Other" and "unable to determine". When I have positive blood cultures I often change the localized infections option to "bacteremia".
I'll be interested to hear what happens with this one. There is so little guidance as to what is/is not ethical/legal in regards to queries, I am constantly second guessing myself as to what is appropriate.
Good Luck!
Katy Good, RN, BSN
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Office: 928.214.3864
Cell: 928.814.9404
Unable to Determine and Disagree are two of the choices...we have this
choice on all of our forms...any suggestions for improvement greatly
appreciated.
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
evanspx@sutterhealth.org
I agree that in cases like this there is not much else you can offer. I have queries like this too. For Example, if anemia is already documented in the record, I have a query which asks for the type/etiology and provides check boxes with types as well as "other" and "unable to determine". But, if I was query for anemia itself, with no documentation of the condition at all but maybe just decreased H/H and documented blood transfusion, I would not have the same check boxes, I would include additional options like "hemodilution" or maybe other hematological conditions. In this instance I would design my query as you did.
Sorry I don't have any brilliant ideas,
Katy Good, RN, BSN
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Office: 928.214.3864
Cell: 928.814.9404
query forms....for instance, we use the criteria published in 2008
Surviving Sepsis
The Medical Staff endorsed the criteria and reviewed each query form .
I believe this helps a facility to define, document and defend coding
decisions and I concur with the previous statement regarding the use of
accepted criteria in a query form. If the chart does NOT meet baseline
criteria for a query for a particular topic, a query will not be
performed by a CDS for that topic.
I do not believe all of the various 3rd parties 'know' or acknowledge
all of the most recent definitions (Acute Kidney Injury) for key
conditions. This, plus a demonstrated lack of knowledge or regard for
some of the basic principles of coding as stated in the denial
notifications leads me to believe we should appeal vigorously any and
all cases where it is reasonable to do so.
Paul Evans, RHIA, CCS, CCS-)
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
evanspx@sutterhealth.org
I agree with Paul & the original poster, a query is NOT leading when reasonable clinical options are presented in a multiple choice format. Open ended questions for most are not as effective.
HOWEVER, I would be more comfortable with the original posted example if there were at least one option offerred that would have ended somewhere other than sepsis DRG (SIRS, SIRS d/t infections, Sepsis are what were stated). A better format would be to include one additional option of "pneumonia (or whatever the infectious process existed in this case) without SIRS or Sepsis".
One other point, was the admission AFTER the release of the current AHIMA Query practice brief? The applicable guidance would be that which was in effect at the time of the admit.
Don