December 14, 2016 | | Comments 0
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Review ACDIS advice regarding use of prior information in query creation

Cheryl Ericson

Cheryl Ericson

Last year at around this time, the ACDIS Advisory Board released a white paper reviewing the role of CDI specialists in assessing information in the medical record from prior treatments.

Codes cannot be assigned based on previous conditions. However, there’s a gray area clouding whether CDI professionals can pull information forward to clarify a diagnosis being treated during the current episode of care, says Cheryl Ericson, MS, RN, CCDS, CDIP, manager of CDI services at DHG Healthcare, during an ACDIS Radio discussion on the topic.

ACDIS created the white paper as a means to help CDI programs open a dialogue about such concerns within their facilities and to help CDI managers begin to craft policies and procedures around compliant and ethical practices regarding electronic health record interrogations.

It states:

In particular, CDI specialists face the dilemma of whether to apply information from prior encounters when querying a physician in order to clarify a diagnosis documented in a current admission or episode of care. The CDI profession is divided on this topic: Some are comfortable referencing the historical information within the query when it clarifies a currently documented condition relevant to the current episode of care; however, others believe this practice violates Uniform Hospital Discharge Data Set (UHDDS) definitions regarding an episode of care, as well as coding guidelines.

The paper reviews overarching guidelines and weighs various references such as reporting additional diagnoses and the definition of the term “encounter,” to help CDI programs begin to assess their own practices.

In Arizona where Judy Schade, RN, MSN, CCM, CCDS, works as a CDI specialist at Mayo Clinic Hospital, the population includes a large

Judy Schade

Judy Schade

number of “snowbirds,” retirees who travel to warmer climates for the winter. For these patients, information included in the electronic medical record often represents an important link between the current encounter and conditions which may have developed in another setting since their last hospital visit.

“We might not have the most current information so we need to be careful and to ask the provider where additional information may be needed to validate a diagnosis and pull it forward,” Schade says.

“It’s not enough for the physician to say this is a complex patient,” Ericson says. “They have to document it. If someone has hypertension they’re clinically always going to have hypertension. However, we cannot automatically make that assumption in coding that’s why the physician has to document ‘history of,’ or ‘chronic,’ or something else that is affecting this episode of care and the resources directed toward treating it.”

Such information “is so much more accessible” due to extensive use of electronic health records than it was in the past, ACDIS Director Brian Murphy says. CDI specialists need to determine whether looking back in the medical record, or opting not to look back, artificially limits a CDI professional’s ability to capture diagnosis specificity or whether concerns regarding the compliance of such activities are valid.

For example, Schade cautions that CDI specialists could be pulling forward outdated or inaccurate information as well intentioned as they may be. So “partner with different departments to formulate your policies. We’re moving in a different way of looking at things so we really need to carefully examine this process and develop the best practices,” she says.

The white paper walks through some common concerns but also recommends reviewing recommendations from the Joint Commission, CMS, and your own facility’s compliance, IT, and coding policies, for example.

Editor’s Note: This article originally published in the free eNewsletter CDI Strategies. Subscribe today!

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Filed Under: ACDISAdvisory BoardClinical indicatorsComplianceGrowing your programManagementPolicies & procedures

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Melissa Varnavas About the Author: Melissa Varnavas, is the Associate Director of the Association of Clinical Documentation Improvement Specialists (ACDIS). ACDIS is a community in which CDI professionals share the latest tested tips, tools, and strategies to implement successful CDI programs and achieve professional growth. With more than 5,000 members, its mission is to bring CDI specialists together. To learn more about ACDIS, go to www.acdis.org or call HCPro customer service at 800-650-6787.

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