To query or not to query unspecified diagnosis
Hello everyone,
First of all , I would like to thank all of you for your comments and insights. Your thoughts and expertise are extremely helpful!
I'm hoping you would be willing to share some of your processes in regard to coding and queries in ICD-10.
1. How do you handle the "unspecified diagnosis" in ICD-10? Do you query each one, even if it does not change SOI/ROM or DRG? Are there some that you have decided to query to make sure specificity is captured?
2. Also, are there some diagnosis that you decided NOT to query for specificity? For example, do you query for the type of join t surface, or do you default to "synthetic" if it is not specified? In a vascular bypass, do you query a physician if he does not specify the vein harvested? Are there other decisions that coding/CDI has made in regard to "unspecified" diagnoses?
Your responses and comments are very much welcomed.
Thank you,
Nadja
Nadja Paea, MBA, CCDS |Documentation Specialist
Clinical Documentation Improvement | Legacy Health
Phone 503.413.5246| npaea@lhs.org
First of all , I would like to thank all of you for your comments and insights. Your thoughts and expertise are extremely helpful!
I'm hoping you would be willing to share some of your processes in regard to coding and queries in ICD-10.
1. How do you handle the "unspecified diagnosis" in ICD-10? Do you query each one, even if it does not change SOI/ROM or DRG? Are there some that you have decided to query to make sure specificity is captured?
2. Also, are there some diagnosis that you decided NOT to query for specificity? For example, do you query for the type of join t surface, or do you default to "synthetic" if it is not specified? In a vascular bypass, do you query a physician if he does not specify the vein harvested? Are there other decisions that coding/CDI has made in regard to "unspecified" diagnoses?
Your responses and comments are very much welcomed.
Thank you,
Nadja
Nadja Paea, MBA, CCDS |Documentation Specialist
Clinical Documentation Improvement | Legacy Health
Phone 503.413.5246| npaea@lhs.org
Comments
1. diagnoses where additional specificity will add/change SOI/ROM
2. specificity that is required for coding (ie: specificity needed to be able to apply PCS codes)
Over time as our comfort with I-10 increases, I predict that we will expand the areas for which we query. However, we are cognizant of the impact on queries on providers and want to make sure we are not overwhelming them. Initially we will focus on the 'needs'. As documentation issues resolve in certain areas, I am sure we will begin focusing on others.
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
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, September 09, 2015 2:39 PM
To: Kathryn Good
Subject: [cdi_talk] To query or not to query unspecified diagnosis
Hello everyone,
First of all , I would like to thank all of you for your comments and insights. Your thoughts and expertise are extremely helpful!
I'm hoping you would be willing to share some of your processes in regard to coding and queries in ICD-10.
1. How do you handle the "unspecified diagnosis" in ICD-10? Do you query each one, even if it does not change SOI/ROM or DRG? Are there some that you have decided to query to make sure specificity is captured?
2. Also, are there some diagnosis that you decided NOT to query for specificity? For example, do you query for the type of join t surface, or do you default to "synthetic" if it is not specified? In a vascular bypass, do you query a physician if he does not specify the vein harvested? Are there other decisions that coding/CDI has made in regard to "unspecified" diagnoses?
Your responses and comments are very much welcomed.
Thank you,
Nadja
Nadja Paea, MBA, CCDS |Documentation Specialist
Clinical Documentation Improvement | Legacy Health
Phone 503.413.5246| npaea@lhs.org
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Needed to provide clarify in order to compliantly bill (impact $$) (Would include Diagnostic coding as well as PCS if bill can't be dropped 2/2 lack of specificity)
Any Quality Metric may be impacted: ROM, Sepsis Survival Rate, VBP, any other of the many quality metrics impacted by risk-adjusted methodology
Paul Evans, RHIA, CCS, CCS-P, CCDS
We issue a query if:
1. Needed to provide clarify in order to compliantly bill (impact $$) (Would include Diagnostic coding as well as PCS if bill can't be dropped 2/2 lack of specificity)
2. Quality Metric may be impacted: ROM, Sepsis Survival Rate, VBP, any other of the many quality metrics impacted by risk-adjusted methodology
Paul Evans, RHIA, CCS, CCS-P, CCDS
Nadja