Q: What should I do if I see a non-compliant query in the chart? Should I remove it, let my co-worker know, or just leave it in the chart?
A: Addressing non-compliant queries can be tricky. The best course of action would be to share your concerns with your supervisor who can then either confirm your perception of the query being non-complaint or could let you know why he or she feels the query is acceptable. Ask your manager or supervisor to go over any internal query policies to help you better understand your facility’s compliance parameters.
Most facilities have standard query policies and procedures which reflect national standards (such as the 2013 AHIMA/ACDIS “Guidelines for Achieving a Compliant Query Practice” brief). They also have processes in place to help co-workers handle questionable query processes.
If there are no policies and procedures in place (or if you and your coworker are only the two CDI staff querying physicians at your facility) you may want to review the latest query practice information together and approach whatever management team is in place to develop such policies yourselves.
If the query is truly non-compliant, I would definitely want the supervisor to address it rather than you doing so on your own. It may be that the individual needs additional training or it may become a potential performance issue. In which case your manager or supervisor needs to know about the situation and may even need to have a documented conversation with the CDI team member who left the query.
You wouldn’t want to remove the query. The physician may have already reviewed it and responded in his or her progress note. If auditors or internal staff later question where that diagnosis came from, no query trail would exist and you may not be privy to those subsequent questions. If the supervisor or program manager determines the query was indeed non-compliant he or she may need to also circle back to discuss the situation with the physician and/or coding team.
In the beginning, when placing queries for the type of heart failure or urosepsis, you may think that physicians will eventually learn the more specific documentation required and that your queries will no longer be necessary. I innocently thought that I would run reasons to query my physicians. Silly me!
Although not as frequently, I still had to ask those very same questions—hey doc, can you please specify the type of heart failure—years later. But I also found so many other opportunities for clarification as I grew in my understanding of the role and as clinical practice and coding rules changed.
I doubt I would have ever run out of questions, nor will you.
Many of the physicians I first worked with were very supportive and responded to education, queries, conversations etc., positively. Seeing my teaching reflected in their documentation was very encouraging. As with any group of students, however, there will always be the overachievers, the slow to grasp but committed learners, and those that just don’t understand why (nor do they care) clinical documentation matters to so much of the healthcare practice.
One physician (whom I very much learned to appreciate) sat down with me one day and said, “Laurie, did you know on average it takes 12 attempts to train a German shepherd to fetch but it takes 21 years to teach a doctor?”
So don’t worry about job security, because we are not training German shepherds to fetch, we’re helping physicians document the care they provide in a changing healthcare landscape. There will always be a reason to prove how valuable your assistance can be.
The ICD-10 for CDI Boot Camp heads to sunny San Diego, California, December 8-10. The documentation issues that exist with ICD-9 will continue in ICD-10. The ICD-10 for CDI Boot Camp provides strategies that can be implemented immediately to improve documentation and facilitate a smooth transition to ICD-10-CM. ACDIS’ ICD-10 for CDI Boot Camp is the only training developed with CDI specialists in mind. Our instructors have in-the-field CDI experience and know exactly what CDI specialists need to know about the new coding system. You will get a CDI perspective on how to:
- Evaluate, revise, and focus physician educational efforts and queries to meet documentation requirements for ICD-10-CM
- Determine the impact ICD-10-PCS will have on the organization and whether CDI specialists should query for surgical procedures
- Highlight changes from the ICD-9-CM to ICD-10-CM Official Coding Guidelines so that CDI specialists can get coders the specificity needed
- Recognize how ICD-10-CM documentation requirements will affect principal diagnosis selection, additional diagnosis reporting, and diagnosis sequencing
- Identify solutions that will maximize efficiency and limit productivity losses during and after the transition
We’ll be in San Diego in December, Las Vegas in February, and Orlando in March. Won’t you join us? Click here to learn more about the ICD-10 for CDI Boot Camp or call us at 800-650-6787.
The 2015 CDI Pocket Guide helps you take clinical findings and dig deeper, and look for additional details—such as medications and other conditions—to develop the most accurate picture of the patient’s condition.
Authors Richard D. Pinson, MD, FACP, CCS, and Cynthia L. Tang, RHIA, CCS, draw on more than fifty years’ cumulative experience and provide the clinical coding authority to strengthen patient care quality and resource utilization, and improve compliance and reimbursement.
The new 2015 edition of our popular CDI best-seller includes critical new updates from the 2015 IPPS Final Rule, and additional ICD-10 documentation tips to ensure you are ready for the national Oct. 1, 2015 compliance deadline. New to this year is additional information on Value-Based Purchasing (VBP) and how CDI specialists can incorporate VBP initiatives into their health record reviews.
What’s new in this edition:
- Addition of pediatric clinical indicators and diagnostic criteria
- New Key References for Shock, Neoplasms, Pneumothorax, Functional Quadriplegia, Cystic Fibrosis, Asthma, Intellectual Disability, and more
- Standardized Key References format for each clinical topic: Definition, Diagnostic Criteria, Treatment, References, Coding and Documentation Challenges, and ICD-10
- Content expansion of “MCC/CC” section to “Comorbid Conditions” that includes secondary diagnoses with a high impact focus for MS-DRG and APR-DRG, quality, and CMS Pay for Performance outcome metrics
- Strategies for integrating CMS Pay for Performance initiatives into your CDI program
- Expanded Reference citations of medical literature and other authoritative sources to support diagnostic definitions and criteria
- Exclusive web-based resource center with detailed supplemental information and updates for all CDI Pocket Guide customers
- Expanded and updated ICD-10 tips and strategies
Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo of you, something you most likely wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We’ve picked up the theme going back into our CDI archives to highlight some salient CDI tid-bit (rather than our fashion sense or lack there-of). Today, we’ve chosen to the CDI Journal article “Take a closer look when reviewing lung cancer charts” which originally published in the April 2011 edition.
by Helen Walker, MD
Lung cancer is the principal diagnosis in about 150,000 hospital admissions per year and a secondary diagnosis for roughly 386,000 admissions. Patients admitted with lung cancer either as a primary or secondary diagnosis require a longer length of stay than an average admission (source: Healthcare Cost and Utilization Project website, http://hcup-us.ahrq.gov). CDI specialists should know what to look for when reviewing cancer admissions in order to capture the true severity of these patients’ illnesses.
The ICD-9 codes related to lung cancer are assigned based on the following factors:
- Documentation of a lung malignancy
- Type of cancer
- What part of the lung is involved
- Whether the cancer is primary or secondary
Often patients are discharged with the diagnosis of “possible” or “probable” cancer when the pathology report is still pending. Although “probable,” “suspected,” “likely,” “possible,” and “still to be ruled out” diagnoses can still be coded as a malignancy, it is best to have the attending physician provide documentation. The department in charge of the post-discharge query process (typically CDI or HIM) should query the physician if the pathology report returns after discharge.
The majority of lung cancers are non-small-cell carcinomas. These include the following:
- Squamous cell carcinoma
- Large-cell carcinomas
- Non-small-cell/non-large-cell carcinomas
Thirteen percent of all lung cancers are small-cell carcinomas. Look for documentation to establish whether the lung cancer is primary or secondary. Many cancers metastasize to the lungs, including breast cancer, gastrointestinal tumors, kidney cancer, melanoma, sarcomas, lymphomas and leukemias, germ cell tumors, and ovarian cancer. So if there is a question whether a tumor is metastatic to the lung, or from the lung, query the physician.
Note: Walker is vice president of clinical quality at FairCode Associates, LLC, a healthcare consulting firm specializing in DRG and coding audits. Contact her at firstname.lastname@example.org.
Q: I was told that a multiple choice query should have at least four options. Keeping in mind that there may be only one reasonable option in a multiple choice query, what would be a good fourth option for a query about hyperkalemia if the other options are:
A: There are many myths concerning compliant query practices so before automatically accepting a dictum of query parameters go back to the official sources to ensure compliance. By this I mean first reference the most recent guidance from the Association of Health Information Management Association (AHIMA) and the Association of Clinical Documentation Improvement Specialists (ACDIS). AHIMA is one of the four cooperating parties (along with CMS, American Hospital Association, and the National Center for Health Statistics) so its recommendations have additional credence should auditors or other investigators question your CDI program practices.
According to the 2013 “Guidelines for Achieving a Compliant Query Practice:”
“Multiple-choice query formats should include clinically significant and reasonable options as supported by the clinical indicators within the medical record, recognizing that there may be only one reasonable option. Multiple-choice query formats should also include additional options such as ‘clinically undetermined’ and ‘other’ that would allow the provider to add free text. Additional options such as ‘not clinically significant’ and ‘integral to’ may be included on the query form if appropriate.”
If you still feel a fourth choice is needed perhaps the choice of “not clinically significant” could be offered. But this would depend on the circumstances of the particular patient encounter.
The 2013 practice brief also provides an option for yes/no queries. However, the brief does recommend that even in yes/no queries that additional options be included, similar to those recommended for multiple-choice queries.
“The ‘yes/no’ query format should be constructed to include the additional options associated with multiple-choice queries (i.e., ‘other,’ ‘clinically undetermined,’ and ‘not clinically significant’ and ‘integral to’). Yes/no queries may not be used in circumstances where only clinical indicators of a condition are present and the condition/diagnosis has yet to be documented in the health record. Also, new diagnoses cannot be derived from a yes/no query.”
Again, refer to the practice brief for additional circumstances where yes/no queries may be warranted and read up on previous practice brief recommendations for a better understanding of how queries should be formatted.