nursing documentation/PICC line

Hi all,

I have a request from coding to place a retro query for the location of the catheter tip for a PICC placement. This is a first for us. The PICC nurse did not document it and we don't have an X-ray showing location. I have never queried anyone other than a provider. Is this something that is typical? Or how would you resolve this issue?

Thanks!

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

Comments

  • We are having the exact same issue!!! Yesterday one of our coders asked how to query for this from the PICC nurse. Currently, they state "PICC placed RUE largest vein". I'm very curious what other places are doing. I was planning to talk with the PICC team and find out from them if they are able to specify with the US what vein they are in. That's my only solution as of now.

    Thanks,
    Cheree


  • Now I'm wondering how many CDS's assist coders with retro queries.....I never know where to draw our boundaries!

    Best Regards,

    Cari Merlina RN, BSN
    Clinical Documentation Improvement Specialist
    Revenue Cycle
    Yampa Valley Medical Center
    1024 Central Park Dr
    Steamboat Springs, CO 80487
    p.970.871.2425
    f.970.875.2796
    Cari.merlina@yvmc.org
    [yvmc]







  • I most definitely assist our coders with retro queries. They often will come to me because they are unsure of something in the chart, or unsure whether they should query or not. I think we need to be this type of resource for them. Jennifer DesJardins RN,BSN,CDIS


  • edited May 2016
    Yes, we handle all the retro queries. I have just never been asked to query nursing. No education as far as how to answer queries has been provided for nursing as this has not come up prior. We have an electronic query process.

    I plan on contacting the manager of our PICC team to explain that this is required documentation but I am curious if others are having this issue and how it is being handled.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • Interesting. I feel that after the patient is discharged, it is the coder/HIM manager responsibility to do their own querying. I'll be interested to meet others at the conference next week to see how others handle this!

    Best Regards,

    Cari Merlina RN, BSN
    Clinical Documentation Improvement Specialist
    Revenue Cycle
    Yampa Valley Medical Center
    1024 Central Park Dr
    Steamboat Springs, CO 80487
    p.970.871.2425
    f.970.875.2796
    Cari.merlina@yvmc.org
    [yvmc]







  • We often assist coders on RETRO queries-and often on patients we haven't reviewed (currently we review only Medicare) that are non-Medicare. We don't mind. Our process is 99% electronic and it often takes the burden off the coders who are already under a great deal of pressure to code the chart because we are short coders here!

    Juli
    Juli Bovard RN CCDS
    Certified Clinical Documentation Specialist
    Clinical Effectiveness/Clinical Quality
    Rapid City Regional Hospital
    755-8426 (work)
    786-2677 (cell)
    "No Limit to Better......"
    [CCDS_pin_1inch]




  • edited May 2016
    We took on all retro queries a couple years ago. I find it beneficial to all parties. Coders appreciate it because CDI's tend to have better access to providers than coding does as we have existing relationships and can track the MD's down if needed. Having CDI place all the queries means that out queries are more consistent which I find is nice for the providers. And for CDI, it is very helpful to have the communication back from coding as to when query opportunities were missed concurrently. This is great education for CDI. Prior to taking this on, I had asked the coding manager to report back monthly as to volume and subject for retro queries because I think this is something that is important for CDI to know.


    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • We do about 98% of retro queries needed on patients that we reviewed concurrently (Medicare & Medicaid); and we also assist with any other queries they may ask us to help with, whether it be Medicare, Medicaid, or commercial.

    Sharon Cooper, BSN, RN-BC, CCS, CDIP, CCDS, CHTS-CP
    AHIMA-Approved ICD-10-CM/PCS Trainer/Ambassador
    Manager Clinical Documentation/Appeals

    Owensboro Health Regional Hospital
    P.O. Box 20007
    Owensboro, KY 42304-0007
    Office: 270-417-4612
    Cell: 270-316-9088
    Fax: 1-270-417-4609


  • edited May 2016
    Katy - if you are electronic, can you talk to the Informatics dept to put
    a hard stop on this procedure so that IR or the PICC Nurses documents the
    required site?

    Christina Franklin, RN, CCDS
    Clinical Documentation Review Specialist
    Health Information Management
    Mary Washington Healthcare System

    1201B Sam Perry Blvd.
    Suite 210
    Fredericksburg, Va 22401

    540-741-6276
    Christina.Franklin@mwhc.com




  • edited May 2016
    Ha! Good point, Interestingly enough. Our PICC nurses are the ONLY ones still documenting on paper….

    I am assuming this will be changing soon. Our providers/queries have been electronic for years (2012). One of the things I want to ask their manager is if they are in the process of designing a template for PICC insertions so that we can make sure that this information is included on the template.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • I am not sure if CDIS can query PICC Nurses ( as they are not recognized as providers). I agree with your plan of talking to their manager and resolve the issue at the source. I am sure if the PICC Nurses are aware of the documentation need, they'll include the needed specificity.
  • edited May 2016
    Keep in mind that when coding PICC lines, the point of insertion does not matter. It is the site where the cath tip ends up or resides that needs to documented.
    [cid:image001.png@01D1B03C.2E691520]

    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way
    Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    Fax: 213-202-6490
    ssalinas@barlow2000.org


  • edited May 2016
    If you don't have an xray there is no way anyone can tell where the line ends. They may have cm of insertion length but that is it


  • edited May 2016
    Yes, in this case we have the insertion length but nothing more. So what do we do in this situation?

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • I audited our PICC documentation prior to ICD-10 and found that (thankfully) the tip location is documented on all..it's part of their protocol to have an MD review the x-ray and state where the tip is. I am wondering if the case you are referencing is a mid line catheter where the tip isn't central, they do some of these on our adults. What does your facility use to determine that the PICC is indeed central and not kinked, etc..

    Thanks,
    Jeff
  • edited May 2016
    We can't even use a line here without xray showing where tip is. I don't think anyone can answer it


  • I really think you are going to need a statement by a Provider as to where the tip is or either an imaging report. Definitely want to collaborate with them ASAP and see what their policies are for verification, etc... maybe this was a midline cath that isn't central?

    Jeff
  • edited May 2016
    Yes. This is my issue. There was no xray so I am not sure how they would know.

    Setting up a meeting with their manager to better understand their process....

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404



  • For patient safety purposes, we have a PICC (Peripherally Inserted Central Catheter) Policy and Procedure
    PURPOSE: To provide guidelines for safe insertion, tip repositioning, maintenance, de-clotting, and removal of peripherally inserted central catheters.
    One (of many) policy statements: A Chest x-ray is ordered for all PICC insertions. The physician or designee is responsible for the verification of correct placement for PICCs via chest x-ray.

    The chest x-ray not only ensures the correct placement prior to using the PICC, it also provides the tip location for accurate ICD-10-PCS coding.

    As others have stated, without an x-ray, it would be impossible to answer the query with certainty.

    Donna F.


  • edited May 2016
    Update:

    The PICC team has a new electronic form they are documenting on. It is housed in a location for forms which we do not typically look at which is why coding and CDI did not know about it. Now we do!

    As for the lack of chest xrays, they are using a 'vascular positioning system' which replaces the chest xray for the vast majority of patients. It uses ultrasound and EEG for placement.




    Learn something new every day!!


    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • That's really cool!! You do learn something new every day! It does amaze me how many changes are made in the clinical arena and nobody thinks about the downstream effects. For example, our PICC insertion, Dietician's notes/assessments and PT notes/assessments went live on the EMR sometime last year. I was killing myself looking for this info and then tracked someone down who told me. Nobody informed the Coding Mgr or anyone...

    Jeff
  • If they are only using the us/ placment system with the waveform and no CXR. How do we document the correct location for the tip? Our reports state picc inserted RUE via guidance good waveform.  Please advise.

    Cyndy

  • chiddink said:

    If they are only using the us/ placment system with the waveform and no CXR. How do we document the correct location for the tip? Our reports state picc inserted RUE via guidance good waveform.  Please advise.

    Cyndy


    Our adult PICC team is now using the Sherlock 3CG system. They place the ECG tracing in the chart and it has a statement on there that "based on ECG tracing, the tip resides in the SVC". They have set criteria they use for when to obtain a chest x-ray. It's a very neat system...I had to google it and found youtube videos demonstrating.

    I wrote Coding Clinic before we had the information about the print out and they stated if the system confirmed that the tip on the line resides in the SVC or cavoatrial junction, assign SVC.

    Hope this helps a little. You might ask your PICC team if they have the capability to print the waveform and if it has a statement regarding line placement.

    Thanks,

    Jeff

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