December 06, 2010 | | Comments 1
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Ethics brief offers CDI reminders for appropriate practices

The American Health Information Management Association (AHIMA) released its Ethical Standards for Clinical

AHIMA ethics guidance offers CDI reminders

Documentation Improvement (CDI) Professionals paper earlier this year.  Hopefully, the majority of CDI professionals have taken the time to read the document in its entirety and have assimilated the material to your business practice of CDI. If you have not had the opportunity to read AHIMA’s CDI ethics  brief, now is the time to clear off your desk and begin the task.

The AHIMA paper highlights key provisions of ethical standards governing the practice of CDI that serves as an underlying foundation of our profession. These ethical standards are based on the AHIMA’s Code of Ethics, its Standards for Ethical Coding, as well as the Association of Clinical Documentation Improvement Specialists’ (ACDIS) Code of Ethics.

Basic points

Common sense points governing the roles, duties, and responsibilities of a CDI specialists are presented within the paper. While the information provided is certainly logical and congruent with the philosophy that we ascribe to as CDI professionals, it is worth mentioning several items that may need reiteration from a practical application standpoint. Consider the following:

  • CDI specialists shall use queries as a communication tool to improve the quality of health record documentation, not to inappropriately increase reimbursement or misrepresent quality of care
  • CDI professionals shall not query the provider when there is no clinical information in the health record prompting the need for a query
  • CDI professionals shall facilitate documentation that supports reporting of diagnoses and procedures such that the organization receives the optimal payment to which the facility is legally entitled, remembering that it is unethical and illegal to increase payment by means that contradict regulatory guidelines
  • CDI professionals shall not misrepresent the patient’s clinical picture through intentional incorrect documentation or omission of diagnoses or procedures, or the addition of supported diagnoses or procedures to inappropriately increase reimbursement, justify medical necessity, improve publicly reported data, or qualify for insurance policy coverage benefits.

These points on face value appear to represent a philosophy that we consistently ascribe to in carrying out CDI efforts. However, in our quest to secure specific, accurate, and detailed clinical documentation in support of a “complete” record, we may be circumventing the clinically accurate and clinically relevant aspect of CDI.

Clinically accurate and clinically relevant

“Clinically accurate” and “clinically relevant” are two terms that are (and should absolutely be) synonymous with CDI initiatives. Our role as CDI specialists incorporates the ability to practically apply our clinical knowledge, clinical core competencies, and skill sets in recognizing opportunities for clarification in documentation in support of patient acuity and severity of illness (SOI), risk of in-hospital and 30-day mortality, 30-day readmission, physician medical decision-making and amount of work performed, medical necessity for hospital admission, services rendered, and MS-DRG assignment as well as medical necessity for physician evaluation and management (E&M) assignment

In our quest to affect positive change and clarification of diagnoses, there exists the real possibility of “convincing” ourselves of the possibility of a diagnosis that prompts us to seek clarification of a particular diagnosis or diagnoses.

Take for example sepsis, a diagnosis that slowly crept to a top three MS-DRG by volume in many hospitals. While there are specific clinical criteria for the physician to employ in making the clinical diagnosis of sepsis with or without severe sepsis, we need to remain aware of the entire clinical picture and clinical context of the patient before taking the initiative to clarify the diagnosis of sepsis.

We need to consider the clinical context of all disease processes to the extent we incorporate our understanding of medicine and contributing clinical factors to diseases. The following clinical criteria are commonly used by physicians in their clinical judgment and arrival at a diagnosis of sepsis:

  • General variables
    • Fever (core temperature >38.3°C)
    • Hypothermia (core temperature <36°C)
    • Heart rate >90 /min or >2 SD above the normal value for age
    • Tachypnea
    • Altered mental status
    • Significant edema or positive fluid balance (>20 mL/kg over 24 hrs)
  • Hemodynamic variables
    • Arterial hypotension (SBP <90 mm Hg, MAP <70, or an SBP decrease >40 mm Hg in adults or <2 SD below normal for age)
    • SvO2 >70%b
    • Cardiac index (CI) >3.5 L.min-1.M-23
  • Organ dysfunction variables
    • Arterial hypoxemia (PaO2/FIO2 <300)
    • Acute oliguria (urine output <0.5 mL.kg-1.hr-1 or 45 mmol/L for at least 2 hrs)
    • Creatinine increase >0.5 mg/dL
    • Coagulation abnormalities (INR >1.5 or aPTT >60 secs)
    • Ileus (absent bowel sounds)
    • Thrombocytopenia (platelet count <100,000 /mm3)
    • Hyperbilirubinemia (plasma total bilirubin >4 mg/dL or 70 mmol/L)
  • Tissue perfusion variables
    • Hyperlactatemia (>1 mmol/L)
    • Decreased capillary refill or mottling

A diagnosis of sepsis does not strictly hinge on the absence or presence of the above clinical criteria. The fact that the patient’s medical record includes documentation of some of the above criteria does not itself warrant a physician query for sepsis each and every time.

The same holds true for acute encephalopathy, whether it be toxic encephalopathy, metabolic encephalopathy, septic encephalopathy, or traumatic. I have recently seen CDI specialists query a physician for encephalopathy in the face of a patient with a simple UTI. In another instance, a CDI specialist queried a physician for encephalopathy in the clinical setting of patient sun downing, a term that refers to a state of confusion at the end of the day and into the night. Sun downing isn’t a disease, but a symptom that often occurs in people with dementia, such as Alzheimer’s disease. While the cause isn’t well understood, contributing factors include fatigue, low lighting, and increased shadows.

The underlying theme in these two cases was the patient had a brief change in mental status associated with the patient’s underlying disease state prompting a brief episode of altered mental status or confusion which may or may not warrant a clinical clarification for encephalopathy. By the way, these cases were short stay admissions which, by adding the diagnosis of “encephalopathy,” allowed for the capture of a MCC. In doing so, however, these cases could certainly having capturing the RAC’s attention and ultimately cause a denial of the claim and further RAC audits.

True to clinical documentation

Let’s not forget the clinical knowledge and its practical application as part of our duties and responsibilities at meaningful CDI program. CDI by its very nature must incorporate and embrace the concept of clinical medicine to distinguish and reflect the goals and objectives of affecting positive change in overall physician behavior modification in general patterns of documentation.

For the sake of ethics and compliance, let’s avoid our programs being relegated to one of reimbursement documentation improvement. Reimbursement improvement is a byproduct of clinical documentation specificity and accuracy as opposed to the ultimate endpoint. To think and act only in regard to increasing revenue for the facility actually  increases potential financial liability for the hospital in the form of RAC, Medicare Administrative Contractors, Medicaid Integrity Contractors, and other third party initiatives to identify and recoup provider improper payments.

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Filed Under: AHIMAPhysician queriesRACS

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Glenn Krauss About the Author: Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, is Executive Director of the Foundation for Physician Documentation Integrity.

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