Q: In my facility, we are supposed to send an e-mail to our physician advisor (PA) and to administration if a query is not answered within a week. However, this policy doesn’t work well because administration does not do anything with that information, and the PA doesn’t have time to review unanswered queries. Do you have any suggestions concerning when to let a query go unanswered?
A: We do suggest every CDI program have well-developed query policies. These should be consistent with those policies followed by the coding department. Look at how unanswered queries are addressed on the retrospective side.
Your query policies should include clear guidance on what instances queries are to be asked, where they are placed within the record, and who is responsible for follow-through. You should also have guidance on how queries are to be prioritized.
Query policies should also include an escalation policy that describes how to handle situations in which an answer is not received, an inappropriate answer or comment is provided, etc. The escalation policy should address when the issue is brought to the physician advisor, your department director, or administration with defined actions as to the responsibilities at each level. The policies should reflect a method of response that can realistically occur for your organization.
In my experience, if a query was unanswered, the CDI specialist and inpatient coder would discuss the need for follow up. If it was determined that the answer would provide little impact, we would close it, leaving the query unanswered. But if we concluded an answer was required, the CDI specialist would address with the provider. There was a process of escalation in those instances when no response was received.
Ultimately, your policies should indicate what instances a query can go unanswered, and when it should be followed through. There may be instances when a query does not impact the reimbursement or quality measures and can be left unanswered. These are conversations that must be discussed within your organization.
Few organizations can boast a query response rate of 100%, but there are some things you can do to boost response rates. Take a look at your query templates or perform a query audit. There should always be choices that allow the physician to offer his or her own interpretation, or to state that there is no significance or the answer is unknown. Often, physicians do not answer queries because they either do not like the choices offered or they are unsure exactly what is being asked.
It might be helpful to monitor physician query response rate based on the CDI specialist responsible for the account. You may find a specific CDI specialist is having difficulty writing effective queries or lacks assertiveness in follow-up on unanswered queries. Most programs have a set time limit or goal for queries to be answered that is tied to individual CDI productivity or effectiveness in the role. For example, an expectation that 80% of all queries asked will be answered within 48 hours.
Administrative support is invaluable in encouraging physician involvement in your program. Many organizations track physician response rates to queries in their physician profiling, or “quality report card” efforts. Instead of forwarding administration every unanswered query, set an acceptable response rate. When a physician falls below the suggested benchmark, the matter should be addressed by a department director, PA, or senior administration.
I also like to give positive reinforcement where it is due. Recognize those physicians who are working with you and are demonstrating a high response rate. It creates a sense of competition and, often, we catch more flies with honey.
Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at firstname.lastname@example.org. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview. The next Boot Camp will be held April 27–30, 2015, in Washington, D.C.
If you attended the 2014 ACDIS National Conference in Las Vegas, Nevada, then you know how wonderful it feels to suddenly be surrounded by hundreds of your peers, people who understand, and love, the same aspects of the profession as you. Take a look back at last year’s conference with a couple of special supplements and relive some of the highlights:
- A slideshow video presents some of last year’s photo memories
- Our Conference Special Section in the CDI Journal recaps some of the learning highlights, fetes our annual award winners, thanks our exhibitors and sponsors, and illustrates just how much fun an ACDIS conference can be.
To help you get revved up and rearing to go this year, we’re previewing a handful of speakers throughout the coming weeks to give you a feel for the sessions. This week, we spoke with Adelaide M. La Rosa, RN, BSN, CCDS, who, along with J. Peter Savini, BA, MHA will present “Revenue Cycle: Overview and Its Relationship to CDI.”
Q: Why is it important to understand the revenue cycle’s relationship with CDI?
A: As CDI specialists, our job is to make sure that whatever has been provided as care is accurately documented so it can appropriately translate to codes. When we put coding out there, we are determining the payment the hospital is entitled to and the DRG it is going to get. If we as CDI specialists are helping present the true overview of treatment and are capturing information, getting physicians engaged, and making sure there is complete coding, the end result will be long-term financial stability. Hospitals know expected revenues and plan budgets ad goals for what they need to do, and these budgets impact case mix and the patient population. It is important for CDI to understand that their day-to-day functions are part of what is driving the revenue cycle.
Q: How is your topic important for everyone in the CDI role, regardless of professional background?
A: There is a financial and clinical balance that must be taking place every day, and CDI needs to know what that means. They need to be aware of cash billed versus cash received and ask what patients we should be looking at to see additional opportunities. CDI specialists cannot just see themselves as simply getting diagnoses, CCs, and MCCs. They can play a significant role in finding a population of patients for review opportunities.
Q: As an RN, how does your perspective differ from other professionals performing the CDI role?
A: Having been on the floor as a nurse, I have communication skills to query physicians and the clinical background to understand what is going on. That clinical knowledge is very important. However, those without clinical experience, like coders, aren’t unfit for the job—but it does help expand how you would further review a chart.
Q: How did you become interested in CDI?
A: I did bedside nursing and floor nursing, and was always very driven about understanding when DRGs were coming into play and what that was all about. I was fascinated by the reimbursement aspect, too, and wanted to take my clinical knowledge and apply it to a different role. I may not be directly touching the patients with CDI, but there is an indirect impact, making sure the communication of care is clearly documented in the chart, so anyone picking up the chart can understand what’s going on.
Q: What are you most looking forward to at the ACDIS conference?
A: Meeting other professionals and networking. I’ve been doing this a long time, and am always interested in what else I can learn to grow as a leader, further enhance my clinical knowledge, and further understand the world. ACDIS does a great job of bringing a team of professionals together and offering them different breakouts that are great for new or experienced CDI professionals.
If everyone passed the Certified Clinical Documentation Specialist (CCDS) credential exam it wouldn’t be a very valid test would it? We hear from people who are surprised, even embarrassed, if they fail. They tell us that there has to be a mistake. They passed their nursing boards with ease. They’ve never failed an exam in their lives.
Although perfectly true, past successes don’t necessarily mean that an individual will be able to pass the CCDS exam—not everyone passes this exam the first time they take it. We have people who don’t pass until their third or fourth attempt. We had one persistent CDI specialist who remained confident and determined—and passed on her fifth try.
Here are our exam stats for the January and February 2015:
- First time testers: 114; Passed 84 (75.7%); Failed 27 (24.3%); Absent 3
- Repeat testers: 20; Passed 11 (55%); Failed 9 (45%)
- Total testers: 131; Passed 95 (72.5%); Failed 36 (27.5%); Absent 3
Here are the exam stats for 2014:
- First time testers: 696; Passed 531 (75.4%); Failed 165 (23.7%); Absent 14
- Repeat testers: 131; Passed 89 (67.9%); Failed 42 (32.1%); Absent 4
- Total testers: 827; Passed 620 (75%); Failed 207 (25%); Absent 18
The overall pass rate for 2103 was 75.5%; the first-time pass rate of about 76% means that there are plenty of smart, savvy, experienced, veteran CDI professionals who are not successful on their first attempt.
The CCDS Exam Study Guide continues to be the only printed reference for exam prep assistance. Our CDI Boot Camps are excellent programs to build your CDI foundation and fundamentals, but none are designed or promoted to be exam prep courses. Experience is the best preparation tool. And remember, because the CCDS credential was designed as a mark of experience and excellence, those wishing to obtain certification need to have at least two years’ experience before they can sit for the exam. Even if you have the minimum experience required, you may just need a little more time in the position. Consider waiting just a bit—give yourself the advantage of a stronger foundation.
Talk to your colleagues and ask them to share their expertise. If you are an ACDIS member, get onto the CDI Talk group and ask Talkers to share their experiences. Search the Talk archives for threads about exam prep.
If you have one, connect with your local ACDIS chapter and find others who are studying (here is the local chapter link from the ACDIS web site). A study group can be very successful. If you don’t have a local chapter, reach out to your co-workers, or find study partners over CDI Talk, and develop on online conversation to help you prepare.
If you have questions, review the CCDS handbook on the ACDIS website, or reach out to me. I’m here to answer your questions. We wish you the best as you continue to strive for your CCDS certification.
Your organization may have polices dictating the frequency of record review and re-review, as well as how to determine which records CDI specialists should target for such efforts. Be sure to discuss such parameters and the expectations of the CDI staff within them. The staffing of your CDI department as compared to the number of admission/discharges may also influence standard practices of repeat reviews.
Repeat reviews should examine any physician orders written since the date of the last review for any changes in the plan of care or abrupt discontinuation of a treatment (which may indicate a possible condition was ruled out). Review any diagnostic test or study results, progress notes, and assessments for consistency, incongruity, or ambiguity, as set forth by the Association for Clinical Documentation Improvement Specialists and the American Health Information Management Association physician query practice briefs as reasons for queries.
In general, not all records need to be reviewed every day, but repeat reviews should be scheduled for records in which:
- A principal diagnosis has not yet been determined
- A symptom is identified as the principal diagnosis
- An open query is pending
- A surgical intervention occurred
- The patient required a change in care level (either to an intensive care unit or shift from ICU to a general medical unit)
The mission or focus of the CDI department also influences the practice of repeat record reviews. Programs reviewing records primarily for reimbursement typically stop reviewing the record once no further changes in MS-DRG can be made. Those reviewing for severity of illness/risk of mortality most likely review records repeatedly until discharge, to ensure every possible secondary diagnosis gets identified.
Editor’s Note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Complete Training Guide by Laurie L. Prescott, MSN, RN, CCDS, CDIP.
Editor’s Note: CDI Talk is a networking forum for ACDIS members, in which members ask pressing questions and garner the opinion and expertise of their peers. Join by clicking on the CDI Talk tab on the ACDIS website.
Academic medical centers face a whole different set of challenges when it comes to CDI. In one recent discussion on CDI Talk, users discussed how academic medical centers assign queries, specifically if they should address the query to the treating resident or the attending physician. Users also debated whether or not they should require a co-signature for resident’s answers from the attending, and if the same policies apply to nurse practitioners (NPs) and physician assistants (PAs).
Query processes should be outlined in hospital by-laws, says Angelisa Romanello, RN, BSN, FNS, CCDS, CDI Manager at the CJW Medical Center in Richmond, Virginia. For example, per her facility’s by-laws, CDI specialists only query residents, NPs, and PAs who work for their hospitalist group. For any the service line, the attending has to be queried. This helps hold the attending responsible for their students, she says.
Clinicians are licensed to “establish a diagnosis independently,” Sutter West Bay in San Francisco, California doesn’t require a countersignature for NPs and PAs, says Paul Evans, RHIA, CCS, CCS-P, CCDS, manager of the CDI program there. Residents, however, are required to have any and all notes, including a query response, counter-signed by the attending, as per their hospital’s by-laws.
“If a resident is working with an attending, we send the query to the attending,” says Evans. “Often, the attending will expect the resident to answer our query, and that query must then be signed by the attending.”
State laws are important to consider when speaking to the responsibility of the attending physicians in terms of resident oversight and medical records, according to Robert Billerbeck, MC, CPC, owner of Meditco LLC in Colorado. Colorado law considers NPs a “Licensed Independent Practitioner” (LIP) for primary care, and therefore require no co-signature. However, the state law does require a PA to obtain a co-signature and other oversight. Facilities, he says, may have their own rules that meet state regulations, but some facilities’ in-house rules go further than others. For example, a facility can require an MD co-signature for NPs, even though the state does not require it, and other facilities may not have the same requirement. And rules differ from state to state.
“The bottom line is we need to know both state and facility rules when determining signature requirements for any given location,” says Billerbeck.
Residents are often more open to CDI efforts than seasoned physicians, says Deborah Dallen, RN, CCDS, CDI Supervisor at Einstein Medical Center in Philadelphia, Pennsylvania. Her team queries residents, PAs, and NPs on any service. Queries are usually assigned to the primary team with the exception of debridement and OR report clarifications, which are usually assigned to the surgical resident or attending physician. Dallen and her staff have an excellent response rate with residents and, despite the required 24-hour turnaround requirement, they usually meet their deadlines both concurrently and post-discharge.
Queries are not always formally mentioned in hospital bylaws, however, says Katy Good, RN, BSN, CCDS, CCS, CDI Program Coordinator, and AHIMA Approved ICD-10CM/PCS Trainer at Flagstaff Medical Center in Arizona. Many facilities treat queries like progress notes, and maintain them as a permanent part of the medical record. The guidelines for progress notes indicate who can independently sign a progress note. If query guidelines are not explicitly outlined in a facility’s by-laws, the guidelines for progress notes can be used when figuring out who can sign queries.
For example, at Good’s facility, by following the guidelines for progress notes and applying them to queries, residents require a co-signature. Further, queries are sent to the attending, and they are responsible for assigning the query to the resident. Similarly, PAs require a co-signature for progress notes at her facility, and therefore CDI specialists do not send queries directly to them. NPs do not require a signature for progress notes, so CDI specialists do send queries directly to them. Check with physician groups about their preferences for handling queries—some who employ NPs will want the queries sent directly to the NP, rather than the surgeons or physicians themselves.
Q: A patient came to the emergency department with shortness of breath. The admitting diagnosis was possible acute coronary syndrome (ACS) due to shortness of breath (SOB) and elevated troponin levels. The ACS was ruled out. Elevated troponin levels were assumed to be due to chronic renal failure (CRF), and no reason was given for SOB. Before discharge, the patient was noted with an elevated temperature and found to have a urinary tract infection (UTI). All treatment was directed at the UTI, and the doctor noted the discharge diagnosis as the UTI. What would be the principal diagnosis in this case?
A: Without knowing all the specifics, and reading how it was presented, I would say the UTI could not be taken as the principal diagnosis. For the UTI to be the principal diagnosis, we would need to query for two pieces of information.
- The first issue would be whether or not the UTI was present on admission. From this description, it does not was appear to have been not present on admission, but the symptoms appeared before discharge.
- The second concern would be to determine whether the UTI was somehow linked to the patient’s presenting symptoms. A UTI and SOB is a difficult connection to make.
If we eliminate the UTI as a choice, even if the majority of treatment was directed towards to the UTI, we have little to work with. I would query for the probable or likely cause of the SOB. If the provider answers with a definitive diagnosis then this would be your principal diagnosis. If not, the symptom of SOB would be your principal diagnosis.
The bigger concern with this patient might be that the wrong status was assigned. This patient most likely should have remained outpatient and placed in observation status until a more definitive diagnosis could be found warranting an inpatient admission.
Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her email@example.com. For information regarding CDI Boot Camps visitwww.hcprobootcamps.com/courses/10040/overview.