RSSAll Entries in the "Clinical indicators" Category

Q&A: Acute pulmonary insufficiency

Have CDI questions?

Have CDI questions?

Q: What should we do about the documentation of “acute pulmonary insufficiency?” What indicators are you using for this in comparison to querying for acute respiratory failure? Acute pulmonary insufficiency is an MCC following surgery but it is also a potential patient safety indicator (PSI) if it’s failure. 

A: Our process is to review the chart and see if it meets clinical evidence for additional specificity such as acute respiratory failure. If it does not, does it meet clinical evidence for acute respiratory distress (now that there is a new code for that condition)? If it does not, then our CDI teams would not query. If it does meet the criteria, we would add all the relevant information from the record on the query and ask the physician if, in his or her medical opinion, the documented acute pulmonary insufficiency could be further specified. [more]

Guest Post, Part 2: Where do we stand with clinical validation?

clinical validation poll(1)

According to an ACDIS poll, 70% conduct clinical validation reviews.

By Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS

At the 2017 ACDIS conference in May, Nelly Leon Chisen, RHIA, director of coding and classification, the executive editor of the American Hospital Association’s (AHA) Coding Clinic provided clarification on the new Official Guidelines for Coding and Reporting, I.A.19 titled “Code Assignment and Clinical Criteria.” (Read last week’s post here.) At the meeting, Nelly explained the Guidelines intended to reaffirm long-standing advice that coding must be based on provider documentation, essentially that:

  • Only the physician, or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis, can “diagnose” the patient.
  • Clinical information published in Coding Clinic does not constitute clinical criteria for establishing a diagnosis, substitute for the provider’s clinical judgement, or eliminate the need for provider documentation regarding the clinical significance of a patient’s medical condition.

[more]

Guest Post, Part 1: Where do we stand with clinical validation?

clinical validation queries

According to a recent survey, 44.88% send 5 or more clinical validation queries monthly.

By Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS

The 2017 Official Guidelines for Coding and Reporting, effective October 1, 2016, contained a new, perplexing, and problematic section I.A.19 titled “Code Assignment and Clinical Criteria,” which states:

“The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists.  The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

This has been incorrectly interpreted by some to mean that clinical validation of documented conditions is no longer required for code assignment on claims.

[more]

Guest Post: Altered mental status remains a challenge in ICD-10-CM – part 2

James Kennedy, MD, CCS, CDIP

James Kennedy, MD, CCS, CDIP

By James Kennedy, MD, CCS, CDIP

Determine the underlying cause of the altered mental status

Remember that the various forms of altered mental states have underlying causes, which, if defined, diagnosed, and documented, accurately represent the patient’s condition for risk-adjustment purposes. Options include:

  • Neurodegenerative disorders. To the extent that it’s possible to state what the underlying degenerative brain disease is, please do so. Options include Alzheimer’s disease, Lewy-body dementia, late effects of multiple strokes, normal pressure hydrocephalus, some cases of Parkinson’s disease, and a host of others. Note: The term “multi-infarct dementia” requires additional documentation that it is the late effect of multiple strokes. Consider the word “encephalopathy” as well (see the next item) when documenting these underlying causes.

[more]

Q&A: Coding chronic kidney disease, hypertension, and diabetes mellitus

LauriePrescott_May 2017

Laurie L. Prescott, RN, MSN, CCDS, CDIP, answered this question

Q: Let’s say a provider documented chronic kidney disease (CKD), 2/2 hypertension (HTN), and diabetes mellitus (DM), and the stage of CKD was not specified, but lab results show patient was in stage 2. Could I assign codes for CKD, stage unspecified, Hypertensive CKD w/ stage 1-4, and Type II DM. Do I need to assign a separate code for HTN?

A: Let’s break down the documentation.

CKD secondary to HTN and DM: With this documentation, we have two combination codes to assign—hypertensive CKD and diabetic CKD. We would also assign a code to reflect the stage of the CKD.

[more]

Guest Post: Altered mental status remains a challenge in ICD-10-CM – part 1

James Kennedy, MD, CCS, CDIP

James Kennedy, MD, CCS, CDIP

By James Kennedy, MD, CCS, CDIP

In ICD-10-CM, defining, diagnosing, and documenting the various forms of altered mental status and their underlying causes remains an ongoing challenge for physicians and their facilities.

Even the esteemed New England Journal of Medicine states that, “‘Altered mental status,’ a nonspecific term that is frequently used to describe alterations in alertness, cognition, or behavior, is commonly encountered in the emergency setting.” If you have a subscription or access through your medical library, review the discussion at www.nejm.org/doi/full/10.1056/NEJMcps1603154. [more]

Q&A: Electronic query formatting

Have CDI questions?

Have CDI questions?

Q: We use an electronic system at our hospital, and find it is difficult to query a physician since we all have our own processes. Would you recommend having a set format for a query that is used electronically?

A: This is going to be contingent on the system your facility uses.

Some EHRs have pretty complex platforms that will allow you to build templates and write a narrative. Here you would write your question, provide all of the appropriate details, and there would be a more formatted, outlined section below where the individual leaving the query can populate the form within that template.

[more]

Summer Reading: Physician Education Discussion Scenarios

LauriePrescott_May 2017

Laurie L. Prescott, MSN, RN, CCDS, CDIP

by Laurie L. Prescott, MSN, RN, CCDS, CDIP

The following clinical scenarios illustrate where clarification would be indicated and include examples of differing communication methods.

Clinical example: The record states the patient was admitted for treatment of pneumonia and the patient was placed on IV antibiotics. A swallow evaluation indicates the patient is at risk for aspiration. The patient is placed on aspiration precautions and thickened liquids. For the coder to assign a code for aspiration pneumonia, the relationship between the pneumonia and aspiration needs to be documented in the record.

Approach #1 (verbal query): “Dr. Smith, I’m Jane from the documentation improvement team. Do you have a minute to work with me? This chart indicates the patient is at risk for aspiration and needs thickened liquids. Could you identify a probable etiology for her pneumonia? The physician responds, “It is probably due to aspiration.” The CDI specialist thanks the physicians and asks, “Could you please clarify that possible cause-and-effect relationship in the record?” She then reminds the physician that “Unlike outpatient coding, the use of possible or probable is permitted and can be coded for inpatient cases.” The physician immediately writes an addendum to his progress note: “Jane, thanks for your help.”  Jane should then document this verbal query and the results as part of the CDI notes for this account. [more]

Q&A: Missing documentation for acute kidney injury

ask ACDIS

Ask ACDIS all your CDI questions!

Q: We are currently coding a chart for an acute kidney injury which has the baseline serum creatinine and urine output missing from the chart. Is there something we can do to identify additional information before we have to query the physician?

[more]

Guest Post: Minute for the medical staff, part 2

James Kennedy, MD, CCS, CDIP

James Kennedy, MD, CCS, CDIP

By James S. Kennedy, MD, CCS, CDIP

Definitions matter

Many clinical documentation improvement (CDI) programs now look to capture risk-adjusted conditions which help improve the capture of a patient’s severity of illness and risk of mortality regardless of setting. Since risk-adjusted outcomes depends on the definitions of coded diagnoses, let’s discuss current literature which supports specific clinical terms:

Shock: a life-threatening, generalized form of acute circulatory failure associated with inadequate oxygen use by the cells. In assessing the potential presence of shock, abnormalities of the skin (degree of cutaneous perfusion); kidneys (urine output); brain (mental status) are examined. While arterial hypotension (defined as systolic blood pressure of less than 90 mmHg, or mean arterial pressure of less than 65 mmHg, or a decrease of greater than or equal to 40 mmHg from baseline), is commonly present, it should not be required to define shock. As such, lactate levels in shock states are typically less than 2 mEq/L (or mmol/L) in shock states. In neonates, significant shock stigmata, such as decreased capillary refill, mottling, cool extremities, and tachycardia, can define shock in the right clinical circumstance.

[more]