June 21, 2015 | | Comments 0
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Sunday Reading: Query Reviews

Start educating physicians now

The CDI’s Guide to ICD-10

Query forms themselves in many cases will help start ICD-10-CM/PCS-related conversations and educational opportunities with providers. Medical staff should be involved in the ongoing creation and review of query forms.

As is the case with ICD-9-CM, the medical staff most closely linked to a particular condition should vet the clinical guidelines incorporated in the query forms as you adapt them to ICD-10-CM/PCS. Many facilities have clinical guidelines to help determine types of congestive heart failure (CHF) based on recent medical literature and as supported by the cardiology department.

The CDI team at the University of North Carolina Healthcare in Chapel Hill reviewed the previously existing content against current documentation trends and trouble spots. They worked with physician advisors on clinical indicators and with the medical staff on the floor by specialty to build consensus and support for queries.

They addressed top documentation concerns by diagnosis, including encephalopathy, pneumonia, sepsis, anemia, and dementia, among others. In doing so, the group found the process served as a unified (and unifying) source of information that helped inform coders attempting to understand clinical indicators for given diseases, by physicians trying to determine documentation requirements, and even by the CDI specialists themselves as they learned how and when to ask appropriate queries.

Editor’s Note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Guide to ICD-10, Second Edition, written by HCPro Boot Camp instructors Jennifer Avery and Cheryl Ericson.



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Filed Under: Book Excerpt


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

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