March 05, 2015 | | Comments 1
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Last Week on CDI Talk: Leading clarifications and proper query examples

Don't neglect nursing notes and nursing education when looking to strengthen your CDI program efforts.

A good clarification summarizes the case and presents the clinical indicators are.

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. Pediatric CDI Talk is a forum specifically designed for CDI specialists in pediatrics. Join by clicking on the CDI Talk tab on the ACDIS website.

In one recent discussion on Pediatric CDI Talk, users discussed examples of malnutrition and acute respiratory failure query templates, as well as query compliance. The tips are applicable to both adult and pediatric CDI.

A good clarification summarizes the case and presents the clinical indicators are, says Katy Good, RN, BSN, CCDS, CCS, CDI Program Coordinator, and AHIMA Approved ICD-10CM/PCS Trainer at Flagstaff Medical Center in Arizona.

Format-wise, many providers prefer simple bullet points for a quick and easy read, says Good. However, some do prefer a narrative, so it is important for the CDI specialist to find out what each physician would like to see in a query. Good generally uses bullets, but will modify to a narrative approach if the query is unusual or complex, and if the narrative style query is more effective in a certain case.

The problem many CDI specialists face, Good says, is often properly wording and formatting the question(s). Any questions must not lead the physician to a particular diagnosis in any way. For example, the CDI specialist cannot ask the physician if a patient has a particular condition. Instead, they must ask the physician to clarify an existing condition with additional specificity, or ask what condition(s) is being treated. It is appropriate to provide options, Good says, but it is also important to include all reasonable options, and to allow the physician to provide an additional response such as “other” and “unable to determine.”

Here are some example queries (download the forms below under “attachments”). Though this was posted on Pediatric CDI Talk, the example queries are for the adult population, which is reflected in the clinical indicators.

In the first query about a malnutrition case, Good suggests including the clinical indicators used, making sure to note where in the record you found them. Then, ask if the physician can further specify the malnutrition as “mild,” “moderate,” “severe,” “other,” or “unable to determine. Be extremely careful when querying for malnutrition as various government agencies and auditors have targeted malnutrition and related activities. (Read a related article on the matter in the March 5 edition of CDI Strategies.)

The second query deals with clarifying a diagnosis. CDI specialists should never ask the provider if a patient has a certain condition. This could introduce a new diagnosis to the medical record and is considered leading. Try using a multiple choice query instead. For example, “Can you please clarify whether the patient is being evaluated/treated for: Acute respiratory failure, Chronic respiratory failure, Acute on chronic respiratory failure, Other, Unable to determine.”

Attachments: 

Malnutrition 

Acute_Resp_Failure_query

 

 

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Katherine Rushlau About the Author: Katherine "Katy" Rushlau is the CDI Editor for ACDIS at HCPro.

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  1. I think that it is important for CDI professionals to read and understand the AHIMA Practice Brief: Guidelines for Achieving a Compliant Query Practice Review. My opinion is that there is widespread misinterpretation of the brief in terms of multiple choices. The brief instructs us to use multiple choices in certain circumstance, not multiple DIAGNOSES. Big difference. The brief also tells us that these choices MUST be clinically relevant and that there may be only one reasonable option. Additionally, multiple choice (again, not diagnoses) formats should also include additional options such as “clinically undetermined” and “other” that would allow the provider to add free text. Historically, queries have presented a myriad of “diagnoses” to the physician, often without any clinical indicators that would support those diagnoses. I’ve seen the choices of critical illness myopathy alongside acute respiratory failure and malnutrition, which have no rhyme or reason and certainly not interchangeable clinical indicators. That, in my opinion is a clear violation of the AHIMA brief. None of us should be throwing the kitchen sink of diagnoses at the physician for the sake of having more than one “choice”.

    I have seen many CDS nursing queries that look like the 20 year old templated queries and it is time for us to understand that we, as health care professionals, have the skills and clinical knowledge to define that one valid diagnosis to present to the physician and support it with clinical indicators, risk factors, and treatment/evaluation. Add your “clinically undetermined” and “other” and you have your multiple “choice” format outlined by the brief.

    I am proposing this: It is time that we as a group of clinicians, develop our own practice brief from a clinical, not coding perspective. We are not querying the physician post discharge for billing purposes. We are in the hospitals concurrently asking for specific diagnoses to fully and accurately reflect the true clinical picture of patient. This is what Medicare has asked us to do. Medicare and all the other payors want an accurate depiction of their patient population. CDS nurses are part of the patient clinical team and are uniquely qualified to present a highly specific diagnosis along with additional “choices”, and create a fully compliant clarification without fear of payor denial and accusations of “leading” the physician.

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