Organizational Defintions

hrodenberghrodenberg
in Physician Advisors

We’re looking at the idea of using organizational definitions as a way to avoid the clinical validation query (aka “A Good Way To Annoy Your Medical Staff.”)  Specifically, we’re exploring using organizational definitions, adopted as policy by the Medical Staff, as way to avoid the CV Query by using the policy as a coding “default; “ ie.  our definition of sepsis is X, the documentation doesn’t meet that criteria, so we’re going to default to code the underlying infection as Principal.  Does anyone have any experience with this idea, know anyone who uses it this way, or have any referrals or contacts?  I’d really appreciate your thoughts.  Thanks!

Comments

  • lprescott1lprescott1
    I would be a bit hesitant to adopt such a policy as every patient is unique and these discussions need to happen. I do suggest developing such criteria and using them to support a clinical validation query but we need to always defer to the attending provider. The Official Guidelines for Coding and Reporting address this in 2017.

    2017 Official Guidelines of Coding & Reporting (Section A.19)

    Code assignment and Clinical Criteria: The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

    This Guideline does not say we shouldn't query for clinical validation and I strongly encourage CDS and coders to continue to do that but established organizational definitions make this process much easier to perform. 

     

  • lpowenlpowen

    Dear Laurie [are you still here? :)] - would this still be your answer today in 2025? We have Documentation Guidelines that are built with Pinson & Tang, ACDIS & AHIMA references plus practice briefs from associated medical oversight groups/organizations. Each year our MRUR endorses these Guidelines as best practice to consolidate our efforts to avoid DRG Denials/Downgrades. CDI uses the Guidelines as a basis for our Clinical Validation Queries as well - a mutually agreed upon definition set for the frequently challenged diagnoses. We feel that they are beneficial for all.

    Does every practitioner use them all consistently, no there is variation.. and if documentation doesn't meet the defined clinical standard CDI nurses query. They are like a shield for us all - an annual covenant agreement for baseline consistency.

    LO

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