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Book Excerpt: Queries in the Medical Record

Some facilities believe that making queries a part of the medical record poses undue risk for CMS contractor scrutiny, and may present some Recovery Audit Contractor (RAC) vulnerabilities (especially regarding asking so-called leading questions) and implications of upcoding. Other facilities see CDI query forms in the medical record as a means of providing transparency. These facilities believe maintenance of the query form within the patient medical record may be used to defend against RAC audits and other government investigations.

CDI program administrators should work with compliance and general council to determine what works best for their specific facilities and set clear policies and procedures for the CDI staff to follow. CDI specialists need to know their facility’s query retention policies and how these policies affect their day-to-day activities. For example, if the queries are not kept as a permanent part of the medical record, where are the queries stored and how can a specialist access them?

Whether query forms become a permanent part of the medical record varies from hospital to hospital, but they should not be used as replacement for proper documentation in the medical record.

The overriding goal of CDI continues to be clear and consistent documentation of the patient’s SOI. Physicians must document treatment for ongoing conditions daily, label conditions no longer requiring treatment as resolved, and identify emerging conditions as they occur.

A good concurrent query process results in appropriate data coded from records in a timely manner. It also allows for a positive relationship to be developed between clinicians and coding professionals. SOI, quality of care measures, and reimbursement will also be positively affected through accurate and timely reporting of ICD-9-CM codes. Accurate and timely reporting of codes allows for a reduction in denials and ensures proper reimbursement and profiling of the hospital and physicians.

Editor’s Note: This article was excerpted from The CCDS Exam Study Guide written by Fran Jurcak, RN, MSN, CCDS. For more information on composing compliant queries and the rules which govern the query process join us for the Friday, March 18, 1 p.m., eastern, audio conference “Physician Queries: Apply Industry Guidance to Improve Procedures and Data Tracking” featuring Andrew Rothschild, MD, MS, MPH, FAAP, CCDS, and Cheryl Ericson, MS, RN.

Q&A: Querying for the link between diabetes and diabetic complications

Q: I am looking for help posing queries regarding the specific link between diabetes and conditions typically considered diabetic complications. Should we always query the physician regarding the link between the presenting symptom and the diabetes?

A: A cause-and-effect relationship between diagnoses may not be assumed and coded unless documented as such by the attending physician; therefore the CDI specialist may need to query the physician to ascertain such documentation defining the connection between diagnoses.

A query form may state that fact as an introductory statement, then summarize the patient’s clinical indications according to information from his or her medical record, and prompt the physician to indicate a potential cause-and-effect relationship if clinically appropriate. Here is sample language you might adapt to your facility’s needs:

Make sure physicians link the cause-and-effect relationship between conditions.

A cause-and-effect relationship between diagnoses may not be assumed and coded unless documented as such by the attending physician. The patient presented with ___________ (“neuropathy”, “diabetes”, and “CKD” as documented in the H/P.). Please document the cause-and-effect relationship, if any, between these conditions and the patient’s diabetes using one (or more) of the following examples as clinically appropriate:

  • Diabetic foot ulcer
  • Diabetic CKD
  • Diabetic neuropathy
  • Diabetes related: foot ulcer/neuropathy/CKD neuropathy/CKD/foot ulcer due to diabetes
  • Other __________________
  • Undetermined

This is one of those main educational messages (cause and effect) that you’ll want to communicate prior to query dissemination to the medical staff. However, the more consistently you ask this type of question, the sooner providers will get used to documenting that relationship appropriately the first time.   In my opinion, repetition and consistency achieves results.

In general, you can always ask:  “Is there a cause-effect relationship between the following conditions ______________ and ________________?  If so, please document this relationship in the progress notes and discharge summary.” Then give appropriate options similar to the ones I listed above.

Some other examples where cause-effect queries are necessary include:

  • Hypertension and heart disease
  • Diabetes and any associated complications (neuro, vascular (PVD), eye, kidney, etc.)
  • Sepsis and localized infection
  • Complications of malignancies (obstruction due to, respiratory condition due to, etc.)

If you base your query policies using AHIMA guidance documents you should be in good shape, but always have any query templates approved by your compliance officer and/or legal counsel before you start using your queries.

My opinion is that there’s nothing inappropriate in telling the providers why you’re asking the question.  In this case, you’re giving them the coding rules, which they did not previously know.

Editor’s Note: Lynne Spryszak, RN, CPC-A, CDI Education Director for HCPro Inc., Danvers, MA, answered this question. Spryszak teaches the CDI Boot Camp and its online version.

Book Excerpt: Documentation pocket cards as physician training tool

Many programs have developed their own home-grown documentation pocket cards, or tip sheets, based on the clinical topics most apropos to their specific facility. Some handouts are a simple piece of paper developed by the CDI team, whereas others are laminated, elaborately formatted cards from consulting companies distributed as part of the initial implementation program.

In general, a pocket guide explains that physicians must document underlying conditions, not simply the signs and symptoms of the concerns, and link the disease to the underlying cause whenever possible. It also directs physicians to document “suspected,” “likely,” or “probable” in the absence of a definitive diagnosis.

Many facilities include prompts for more specific diagnoses such as systemic inflammatory response syndrome (SIRS) and multiple organ failure and an alphabetical list of important conditions frequently forgotten by physicians, such as:

  • Acute exacerbation of chronic obstructive pulmonary disease (COPD)/asthma
  • Malnutrition
  • Metabolic/respiratory acidosis
  • Metabolic/respiratory alkalosis
  • Sepsis/severe sepsis/septic shock
  • Systolic/diastolic heart failure
  • Pneumonia

If generating a tip sheet for your facility, list common nonspecific terms physicians frequently use to describe patient care and compare them to similar ICD-9-CM terms that, when coded, reflect a greater severity of illness (SOI) for the patient. For example, “cystitis” may also be “urosepsis”/ “urinary tract infection (UTI),” or it may be “sepsis due to UTI.” Each term progressively increases the patient’s SOI.(6)

Some tip sheets also include Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) quality measures, history and physical (H&P) documentation, discharge summary consistency, POA, and hospital-acquired conditions (HAC). Employing such cards during both initial and subsequent training programs:

  • Ensures everyone speaks the same language
  • Promotes facility-wide team building
  • Provides additional avenue of education regarding CMS/RAC updates

Editor’s note: This article was taken from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition written by Marion Kruse, MBA, RN, and Heather Taillon, RHIA.

Pamela P. Bensen, MD, MS, FACEP, CEO of Medical Education Programs, Inc. in Buffalo Junction, VA, created a laminated pocket guide for physicians  available in packs of 25.

When asked about anemia

I challenge you to find one textbook of medicine, physiology, or pathology that refers to a category of hematologic abnormality as “acute blood loss anemia.”

Help coders ask physicians the right questions

But coders are very familiar with that term. They may ask a physician whether a patient has acute blood loss anemia. Or they may ask, “What kind of anemia is this?” And physicians essentially have no chance of ever guessing that they are after “acute blood loss anemia” or even “chronic blood loss anemia.”

What coders really want to know is the cause of the patient’s anemia. Was it anemia due to acute blood loss from a ruptured esophageal varix or from a fractured femur? Was it anemia due to chronic blood loss from hematuria from a patient’s multiple bladder polyps or from menometrorrhagia? Was it anemia due to a chronic infection such as chronic osteomyelitis or chronic hepatitis C? Was it anemia due to the patient’s CKD 4?

That’s why the CDI specialists need know how to take that basic coder impulse and help to ask the right question, and obtain the most accurate documentation for the care the physician provided. After all, it’s the end result that counts—and makes everyone happy.

Editor’s note: This article first appeared in the September 2010 edition of Medical Records Briefing.

Book excerpt: Measuring process and outcomes

The long-term viability of a CDI program is incumbent upon being able to show hospital and medical leadership the scope of work performed and how it influences the hospital. The best way to accomplish this is through the creation of a CDI Dashboard that tracks outcomes and operational measures.

Operational measures can help balance the CDI specialists’ workload and pinpoint areas where CDI staff members need additional education. These combined measures will help to identify areas needing improvement so that action plans can be developed. At a minimum, the Dashboard should include the following metrics:

Outcome measures by payer class:

  • Medical CMI
  • Surgical CMI with and without tracheostomies
  • Medical complication and comorbidity (CC) capture rate

    Use a Dashboard to track your program progress.

  • Medical major complication and comorbidity (MCC) capture rate
  • Surgical CC capture rate
  • Surgical MCC capture rate
  • Measurements related to the “key pairings” (now some are triads) as identified by the Office of Inspector General and noted in the PEPPER Report
  • Financial impact based on changes in CMI from baseline measurements

Operational measures:

  • Number and percentage of cases reviewed by CDI specialist
  • Percentage of cases with queries
  • Physician response rate broken down by agree, disagree, and unanswered
  • Percentage of cases where CDI specialist and coder final DRG did not match
  • Variances in results with their related reasons; for example, if the CMI decreases due to the vacation schedule of an internist

Further breakdown is recommended and can be customized to each facility. CMI and CC/MCC capture rate can be compiled by each specialty/medical department, physician, and coder. CDI leadership should produce and distribute the Dashboard to various stakeholders on a monthly basis. The CDI task force should be responsible for analyzing and identifying troublesome patterns and formulating action plans. The CDI steering committee should be responsible for communicating results to the hospital board of directors. The physician advisor should communicate the results to the medical executive committee. Also, hospitals should explore purchasing national benchmarks if their current Dashboard does not include them.

The Association for Clinical Documentation Specialists (ACDIS) is one potential source of benchmark data related to CDI program operational measures. Data for outcome measures include MedPar data and the various companies that provide data mining services.

Editor’s Note: This article was originally published in The Physician Queries Handbook: Guide to Compliant and Effective Communication.

Consistancy and the swimming pool

Hypothetical question: You don’t know how to swim, but you’re learning. You have an inner tube around your waist. Now, where would you rather continue your lessons–in the pool in your backyard or in the ocean?

A friend of mine posed this question to me a long time ago. We were discussing the philosophical importance of

Safe boundaries help create a consistant CDI program.

creating respectful boundaries (a set of concrete rules) in which to raise children. Of course parents will always want to support their children regardless of situation or peril. The inner tube represented that type of support. But he argued that he’d rather learn how to swim in a pool, because the boundaries were obvious (the edge of the pool) and the water clear, free from any hidden dangers (like sea serpents or sharks). Within that realm, he suggested, children could feel comfortable learning the basics–the doggie-paddle per se–of how to navigate in the world. There they could perfect their skills and advance, perhaps even to the breast-stroke, before jumping into the open ocean.

I was reminded of this anecdote when reading a tip Lynne Spryszak, RN, CCDS, CPC-A, CDI education director for HCPro, Inc., in Danvers, MA, wrote for the December 23, 2010 edition of CDI Strategies. She recommended that facilities develop a uniform set of policies and procedures to govern query development and dissemination for everyone regardless of what department originates the query or houses the CDI program. She said:

“Everyone should be querying using the same criteria, whether they’re nurses, coders, or physicians. Number one: It makes your practice consistent. Number two: It makes life easier for everyone.”

In its Guidance for Clinical Documentation Improvement Programs, AHIMA stresses the importance of developing policies and procedures. It states:

“The CDI department must be governed by written policies and procedures. These policies and procedures should be developed with the assistance of other departments affected by clinical documentation, including compliance, case management, and HIM.”

The world is a chaotic place, was the point my old friend attempted to make. We lean on our parental love, guidance, rules, and yes even societal regulations to help make us feel safe. In adapting the analogy to CDI policy and procedure development it seems simple to say that a consistent message from hospital leadership regarding physician queries can help eliminate some of the chaos that competes for physicians’ attentions and coders and CDI specialists best intentions. But it’s like Lynne says: “It makes like easier for everyone.”

If you haven’t yet developed a set of query policies and procedures for your program yet, take a look at the ACDIS Forms & Tools Library or the AHIMA guidance for some samples.

Persistence helps when providing physician documentation

Stephanie Woody, a CDI specialist at St. Joseph’s Hospital and Medical Center, had this Calvin Coolidge quote on her e-mail signature:

“Nothing in this world can take the place of persistence. Talent will not; nothing is more common than

Keep at physician education efforts and you'll be successful.

unsuccessful people with talent. Genius will not; unrewarded genius is almost a proverb. Education will not: the world is full of educated derelicts. Persistence and determination alone are omnipotent. The slogan “press on” has solved and will solve the problems of the human race.”

Woody also has the quote hanging in her office. She says it’s amazing how much she and her CDI teammate have been able to accomplish by simply sticking to the spirit behind the sentiment.

It reminded me of a 2008 article written by Peggy Taulbee and Teri Sholder CDI professionals from Kettering Health Network in Dayton, OH. As they talked about the success of their program at the time, they included some advice about physician education. “Physician education is a daily goal and a continual challenge,” they wrote. “We take every opportunity to enlighten the physicians about coding, documentation, and quality of care standards.”

In their article, Taulbee and Sholder offered some physician education methods that seemed to work at their facility including:

  • Create easy to use to web-based education
  • Hang educational posters in physician lounges
  • Distribute fliers on units to announce upcoming educational sessions
  • Stress the importance of complete documentation on physician and hospital profiles

Many CDI programs employ these tactics. What makes one program more successful than another might be as Coolidge suggests one’s ability to be persistent. Physicians, inundated as they are with directives from all departments, require educational reinforcement. The physician query, when used appropriately, can act as a documentation education tool, of course, but add to it some of the items Taulbee and Sholder recommend and you’ve supported that education exponentially.

This reminds me of a 2010 ACDIS Conference presentation, “Strategies for Achieving Medical Staff Compliance,” by Trey La Charité, MD, physician advisor at University of Tennessee (Knoxville) Memorial Hospital. As part of their CDI program education efforts, the team would regularly pick a group of physicians and perform what La Charité called a “blitz.” During the blitz the team examined every medical record of that group of physicians, hung out in the lounge with them, rounded with them, held educational sessions with them, and provided posters, pocket cards, and other tools to the group. (La Charité’s presentation is located on the Forms & Tools Library.)

Whatever method or methods you chose to help educate physicians and advance your CDI program’s efforts remember Coolidge’s advice and “press on.”

Resources to help CDI with ATN confusion

Further specificity on Acute Renal Failure (ARF)/Acute Kidney Injury (AKI) has become a larger topic with the coding changes that took place October 1, 2010. Personally, I am concerned about being able to ask for clarification when it is actually clinically appropriate to do so versus asking every time any sort of acute renal dysfunction is identified. In that light, I would like to point toward a couple of references I found helpful. (The links to the source material I used as the basis for this discussion are below.)

After reading several resources, it is clear to me that acute tubular necrosis (ATN) in some/many cases is further along a spectrum from ARF. In other words, some of the pre-renal causes of ARF can lead to damage of the kidney and thus develop into ATN. So, all ATN are ARF but not all cases of ARF are also cases of ATN.

CDI specialists should be on the lookout for cases where there is a specified cause for ARF that is not ATN but may be able to be captured with the ICD-9-CM code 584.8, other specified pathological lesion of kidney. According to the sources listed below, common causes of ATN include:

Ischemic (includes some pre-renal causes that are prolonged or severe; occurs when not sufficiently perfused for a long period of time)

  • Hypotension (significant; typically greater than 30 minute duration hypotensive episode)
  • Sepsis
  • Major surgery
  • Hemorrhagic shock
  • Burns


  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Radiocontrast
  • Aminoglycoside antibiotics
  • Free myoglobin or hemoglobin
  • Amphotericin

Instances of toxic ATN are more likely to develop with co-morbidities such as pre-existing chronic kidney disease or diabetes.

Although the patient may be asymptomatic some signs and symptoms include edema/weight gain, uremic symptoms (anorexia, N/V, AMS, etc.), respiratory (shortness of breath, crackles, x-ray findings) and decreased urine output.

Common diagnostic tools include Fractional excretion of sodium (greater than two ( > 2)); UA with casts (not hyaline); blood urea nitrogen (BUN) (mg/dL) and serum creatinine (mg/dL) values/trends and ratio (ATN for 10-15:1, pre-renal greater than 20:1. Electrolytic changes, especially hyperkalemia and metabolic acidosis may be seen. Renal biopsies are helpful, not but not commonly performed.

Treatment is essentially supportive. It is important to differentiate ARF versus ATN. With ARF the typical cause is volume, so treatment is focused around volume replacement. With ATN, the physician will need to identify underlying cause and address that cause in the patient’s treatment.

In my experience, ATN generally takes longer for renal function to return to baseline.  If you see BUN/Cr returning to baseline in less than 48 hours, it is more likely to be ARF due to prerenal causes that rapidly respond to volume replacement.

Here are the sources I mentioned earlier. Don’t forget it always makes good sense to check with your own physicians to see what resources they use.

Documentation improvement programs: Friend or foe?

Many of the nation’s hospitals now have clinical documentation improvement (CDI), management, or integrity programs. They are designed to help physicians improve the documentation of diagnostic or procedural information in inpatient medical records so that the documentation meets the needs of the coding process. There are good things that can come out of these programs, but there can also be bad things.

The first thing for the physician to know is that, if done correctly, a CDI program is one of your best friends. When coders correctly assign the ICD-9-CM (and soon ICD-10) diagnosis and procedure codes, physicians get the following benefits:

  • Proper and accurate representation of patient morbidity and mortality statistics
  • Proper and accurate representation of physician’s thought processes and actions in treating the patient so that physician billing—as well as the hospital’s—is accurate
  • Increased communication among the healthcare providers in dealing so that the most expeditious care can be rendered
  • Improved documentation of physician’s daily thought processes in treating patients or those for whom physician’s are consulting

Let me tell you about some things to look out for, however, because you should probably not participate in the following scenarios:

  • Acute blood loss anemia. After a hip fracture repair, you may see that the 76-year-old female  patient’s hemoglobin dropped from 14 to 12.5 and stabilized. If someone asks the physician to document “acute blood loss anemia,” that’s a problem. First, the  patient is not anemic, so it’s unethical. If the patient’s hemoglobin drops from 14 to 8.5 and she becomes tachycardic and physician decides to either transfuse or provide an iron supplement after discharge, call it “anemia due to acute blood loss from the hip fracture.” That tells the story properly.
  • Acute respiratory failure. If a patient comes to your service on the cardiovascular ICU after a coronary artery bypass graft and is on a ventilator because of morbid obesity, and early extubation would likely lead to problems, don’t document “acute respiratory failure.” The patient is sedated and maintained basically anesthetized on purpose, not due to a disease. Use “ventilator management” in your documentation. However, if the patient develops a disease and must be reintubated, acute respiratory failure becomes appropriate.
  • Systemic inflammatory response syndrome (SIRS). The criteria for a significant infection that the Society of Critical Care Medicine put out in 1991 have undergone considerable modification. Can you recall any patient with acute cholecystitis or acute appendicitis who has not had two of the four criteria of SIRS? Have any of your children had a middle ear infection and did not have a fever and tachycardia because it hurt? Did your child need to be on a critical care unit with a central line, or did he simply need some amoxicillin? SIRS is built into bacterial infections. Don’t describe abnormalities in vital signs or lab results in a patient with a simple bacterial infection as SIRS. When a patient has sepsis, you can tell from across the room. Call that sepsis! Reserve SIRS for noninfectious conditions such as significant burns or necrotizing pancreatitis.
  • Acute kidney injury (AKI). The Acute Kidney Injury Network has written an exhaustive treatise on what is still often referred to as acute renal failure. When a patient has simple dehydration and small bumps in the creatinine level and everything else returns to normal within six hours of fluid resuscitation, it was not AKI. Should an increase in creatinine level from dehydration persist after initial rehydration, then it was AKI. If it resolves, it was dehydration, prerenal azotemia, or acute renal insufficiency.
  • Acute on chronic systolic heart failure. You probably have many patients in your practice who are chronic heart failure (CHF) patients. The specificity of left, right, or biventricular heart failure is important. If you see a patient in your office with left heart failure, differentiate whether it is characterized by systolic or diastolic dysfunction or both. When a patient is admitted to the hospital for acute CHF, document it as “decompensated” plus the chronic state that you know from your office and the echo performed a month ago. If it’s apparent, also document the cause of the acute decompensation. In the hospital, “decompensation” or “exacerbation” is sufficient.
  • Encephalopathy. This is simple. If the patient has a condition that caused encephalopathy, call it whatever specific encephalopathy you can. A person who is simply drunk does not have encephalopathy. A person who took a dozen Elavil as a suicide attempt is tranquilized. These are not encephalopathy.

The issues above mean a lot for you, your patients, and the nursing staff. They’re important in the office as well as the hospital. When a CDI staff member asks a good question that improves informational value, provide all the help you can. But when you are asked to document something you don’t believe in or something unsupported in medical literature, think twice.

Editor’s Note: This article first appeared in the January 2011 edition of Medical Records Briefing.

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.