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Parsing the pregnancy problem

Is reviewing pregnancy cases worth the energy?

Many CDI specialists don’t spend a lot of time working with obstetric (OB) records, or may even ignore them altogether, principally because of the ICD-9-CM Chapter 11 coding guideline that basically says that pregnancy overrides everything else. Furthermore, within MDC 14, the opportunities to affect the DRG are limited, and let’s face it, the reimbursement is abysmal at best, so the CDI team leaves it up to coding to decide what to do with these cases.

But consider what we really can do with these cases. We have occasions in MDC 14 to influence not only DRG assignment, but severity of illness (SOI), risk of mortality (ROM), length of stay (LOS), and hospital-acquired condition (HAC) management. DRG 765/766 is Cesarean section with/without complication/comorbidity (CC) or major CC (MCC). DRG 774 is vaginal delivery with complicating diagnoses, DRG 775 is without complicating diagnoses. DRG 781 and 782 are other antepartum diagnoses with or without medical complications. Right there we have a chance to look at documentation for getting the case into the appropriate DRG. At the same time, when we educate and query physicians about possible comorbidities, we can increase the SOI/ROM scores just as we do with all our other MDCs.

Consider the example of a pregnant patient diagnosed with anemia as a complicating condition prior to her Cesarean. Although Chapter 11 tells us to take complications to a pregnancy code, it also tells us to code the condition itself. If there is evidence of acute blood loss anemia (ABLA) and we do not ask the physician to clarify the diagnosis because we haven’t read the chart, then the DRG is 766, Cesarean section w/o CC/MCC, with a relative weight (RW) of 0.79, a geometric LOS of 2.90, and minor SOI . Compare that with adding documentation of ABLA, bringing the DRG to 765, Cesarean section w/CC, with a RW of 1.12, GLOS of 3.9 days, and moderate SOI.

When we choose not to review OB cases, we lose the ability to assist in documentation of present on admission diagnoses that will prevent the hospital from being charged with a (HAC). For instance, it is not impossible for a pregnant woman to have a stage III pressure ulcer, and it is certainly not unheard of for a pregnant woman to show signs of poor glycemic control such as diabetic ketoacidosis. The obstetricians need to know how to document these diagnoses to protect themselves and the hospital from unwanted and undeserved repercussions.

Then there is the exception to the rule that we all know and love: incidental pregnancy. The Official Guidelines for Coding and Reporting state:

“Should the provider document that the pregnancy is incidental to the encounter, then code V22.2 should be used in place of any Chapter 11 codes. It is the provider’s responsibility to state that the condition being treated is not affecting the pregnancy.”

So what does that mean? How do we define incidental pregnancy? I wish there was a definite rule other than “whatever the physician says it is,” but I have my thoughts.

Occasionally a chart will come onto my caseload because the admitting diagnosis was cholecystitis or a migraine, and I don’t realize until I get into the actual record that the patient is pregnant. My focus becomes determining if the principal diagnosis—the real reason they were admitted and not where it’s going to fall out under MDC 14—is unrelated to the pregnancy, and at the same time, not complicating the pregnancy. I don’t think that getting an OB consult necessarily brings us over to the pregnancy codes, but at the same time, I need to look very closely at that OB consult to see what they are doing and why they are doing it.

In my opinion, if the plan of care is being significantly altered due to the pregnancy state, I’m stuck with pregnancy. If it’s not, then I’m going to think about a query for incidental pregnancy. Maybe the pregnant woman came in because of a dog bite when she is 10 weeks pregnant, gets put on antibiotics, maybe has a minor surgical intervention. The physicians take into account the pregnancy in ordering her medications and managing her care, but it’s really not central to her admission at all. I would send that query.

I might even have a case where the patient was admitted with a broken ankle, and she didn’t even know she was pregnant until the routine bloodwork came back. I would probably send that query, too. On the other hand, I recently followed a patient who came in with an allergic reaction suspected to be due to the medications she was taking for her high risk pregnancy; she refused a CT scan because she was pregnant, and the OB team worked with the hospitalist in managing her every step of the way. I didn’t that situation was incidental and so I didn’t query for it.

I have seen coders make the decision themselves not to code the chart to MDC 14 in the absence of a physician statement, and I’ve seen cases where the physician was queried for incidental pregnancy when it was really evident that the pregnancy could not be unbundled from the medical diagnosis, and I’m not okay with either of those choices. I’m definitely an err-on-the-side-of-caution kind of girl.

So, let me know what you think. What’s your experience with the pregnant population?

Editor’s note: In the April 2010 edition of the CDI Journal readers will find an article weighing the benefits of conducting OB reviews along with a tip sheet for what to watch for

Use radiology findings to support your physician queries

Use clues from radiology and lab findings to help support your queries.

A patient’s medical record contains a wealth of information about his or her hospital encounter, including diagnoses, treatments, operative reports, and ancillary notes. Unfortunately, much of the detailed information found in a patient record is not “code-able”—that is, it is not information that may be used for diagnosis code assignment. Coders may only use documentation contained in select portions of the record—that which is provided by “hands-on” providers (i.e., those providers legally accountable for establishing a diagnosis).

Radiology reports, such as CT and MRI scans, x-rays, and ultrasounds frequently contain detailed information that can lead to more specific code assignment.

Coding Clinic advice supports the use of radiology findings to obtain additional information regarding the coding of the specific site of fractures. See the following references for more information:

  • Coding Clinic, First Quarter, 1999, p. 5 (fracture site specified in radiology report)
  • Coding Clinic, Second Quarter, 2002, p. 3, (ED coding using the radiological findings)

Note, however, that this guidance does not pertain to assigning diagnosis codes for conditions that the treating provider does not specifically identify or document.

Editor’s Note: This article first appeared on ACDIS members can read the entire article when it is published in October edition of CDI Journal.

Physician collaboration: Identifying the keys to success?

How do you get physicians to work with your CDI program?

Over and over again in CDI Talk, at the ACDIS conference, local chapters, anywhere two CDI professionals have an opportunity to  interact, it seems,  some very common topics arise. One of the most common it seems is how to gain cooperation and collaboration of the medical staff in CDI efforts.

An early ACDIS poll (March 2008) asked: “How have physicians reacted to your CDI program and query requests?” The results showed that only 40% reacted positively and the balance either neutral or negative.

I have yet to find the magic pill (imagine me sitting here singing Jefferson Airplane’s “White Rabbit”) which, once taken, will ensure physician collaboration in CDI efforts. If only one actually existed.

In recent ACDIS post titled “The CDI Evolution,” Juanita B. Seel RN, CCDS, described the organic development of her program. One of the things that really struck me was the apparent shift in response of the medical staff as her program focused more on completeness and accuracy of the medical record and away from financial implications of queries.

This idea— how to improve physician collaboration— has been foremost in my thoughts lately.  At my facility here in North Carolina, we are in the process of recruiting a medical director who will devote 50% of his or her time toward CDI/coding/HIMS and the balance to utilization review and case management, so I’ve been thinking A LOT about how to work effectively with this individual. And I’ve been wondering if ensuring physician collaboration is actually really simple.  Is the key truly as simple as finding the right hook, which is severity of illness / risk of mortality?  But there have been so many other things that have been discussed andtried!

How important are the various avenues employed to deliver information and promote better understanding?

  • Newsletters
  • Physician group presentations
  • Fliers or posters
  • Pocket Cards (or small handbooks)
  • Individual on-the-floor ’30 second spots’
  • The content of the queries, especially if attachments are used
  • Web based content / presentations / Q&A
  • Case Studies
  • Support from:
    • Physician Advisor / Champion
    • Hospital Executives
    • Medical Staff Leadership
  • Other??

What are the other things that folks have found to really motivate the medical staff?

  • Public profiling data
    • Core Measures
    • Health Grades
  • Quality of Medical Care
  • Physician E&M billing
    • Support complexity and risks
  • Short term, high intensity service line reviews
  • I know that some organizations include unanswered queries with the delinquent records
  • Other??

This is the single most important challenge that a program MUST overcome to be truly successful. This is one of the most important areas where we can share our success stories, our tools, our unique organizational variations, etc. So, I put it back out to the rest of the CDI community: What has been the single most effective thing that your program has done to engage physicians? AND, what has been the largest barrier for your program to obtaining physician collaboration?

Query questions: When should you not query?

I recently attended the annual meeting of the ACDIS in Orlando where I heard a variety of perspectives during many informative

CDI specialists enjoy the pre-summer air during the 2011 ACDIS Awards Luncheon.


A common thread in many discussions was how to query physicians using information in the medical record and when it’s appropriate to do so. Coders and CDI specialists must remember that a valid diagnosis must be supported by evidence in the body of the medical record. What does this mean?

Let’s consider the often difficult decisions associated with three common diagnoses: Anemia, acute renal failure, and sepsis.


Q&A: Determining factors for query rate increases

How many queries are too many?

Q: I have heard that some facilities have seen their number of generated queries actually increasing rather than decreasing over time. Generally, we hope that by improving the documentation concurrently, we would decrease the need to ask the questions retrospectively. If we’ve been diligent and consistent in our query efforts, shouldn’t the number of our concurrent queries go down also?

A: That is everyone’s overriding goal, certainly, but the realistic picture is that we don’t see it happening. An increase in your facility query rate could be due to physicians’ lack of participation or understanding of your CDI program efforts, or it could represent the fact that physicians have just fallen back into bad old habits. Watch when a physician does dictation. You can almost see him mentally re-envision his initial encounter with the patient; you can see him going head to toe in terms of his assessment and documenting that interaction. When that happens  the physician likely is not thinking about the last query you or your CDI team members left for  him nor is he thinking about the last in-service your team provided on coding differences between ureosepsis and septic shock.  He is simply documenting the care he provided true to same-old habits. For example, the bad habit would be to document CHF, not acute-on-chronic diastolic heart failure.

I do agree with the premise that if we educate and train physicians to document completely and accurately (the way we would like them to), the query rate should go down.

CDI programs also need to remember that coding changes take place every year and what you may have thought you addressed previously can soon require additional training. Don’t forget about the slew of regulatory changes in the works or the need for greater specificity in the medical record documentation associated with the impending implementation of ICD-10. All these changes will most likely increase your query rates.

Like every other metric you use to measure your CDI program success, the query rate needs to be examined within the context of the program, the facility, and the larger changes in healthcare.

Editor’s Note: Fran Jurcak, RN, MSN, CCDS, Director at Huron Healthcare, answered this question during the January 27 audio conference “Clinical Documentation Improvement: Strengthen your program and protect against denials.”

Q&A prompts additional thoughts on CDI staff productivity

My recent Q&A in CDI Strategies (“Productivity Measures for CDI Specialists”) generated a few reader responses so I

How many records should you review in a day? The answer isn't easy.

thought I would take a moment to talk a little more about the record review processes we used as my previous facility.

Generally, my first reviews took about 15-20 minutes since I reviewed them the day after admission and the volume of information in the record wasn’t overwhelming.  During the first review I made notes on my worksheet of anything that I felt needed another look and focused my second reviews on those conditions.  I re-reviewed those records without any queries every other day until discharge so that I didn’t have so much data to comb through.  On follow-ups I reviewed only back to the date of my last review since I had the notes from those earlier examinations to remind me what I needed to watch for.  On subsequent reviews I looked at labs, medications, new orders, procedure notes, ancillary documentation, etc. — but only if it was newly introduced to the record.

If I knew the physician had provided solid documentation for the principal diagnosis, then I focused my follow up reviews on capturing secondary diagnoses if they were not documented well and on Hospital-acquired conditions (HACs).  At that time, I did not have responsibility for core measures or any case management duties.

Of course, the more responsibilities one has in relation to the record will result in reviews that take longer for each chart.  But I typically had about five to 10 new admissions per day (some days were heavier than others), and of course Mondays were frantically busy. We did not review weekend short stay discharges if they were already gone on Monday.  For those records the coders would identify any query opportunities and either query themselves or refer it to a CDI specialist for follow up.

As an aside, the recently released 2010 Physician Query Benchmarking Report illustrates that the majority of CDI specialists (32%) review between six and 10 new patient charts per day, with a slightly smaller number of respondents indicating that their CDI specialists review 11–15 charts daily (31%), as depicted in Figure 32 on p. 18. Rereviews echoed this trend, with 27% indicating they perform between six and 10 rereviews per day and 22% reexamining 11–15 records daily, as depicted in Figure 33 on p. 19.

I’ll also mention that these results were similar to those illustrated in Figure 20 and 21 on p. 41 of the 2010 CDI Program Benchmarking Survey published last July. [more]

Query report: CDI focus primarily on concurrent reviews

CDI programs continue to focus on concurrent review (98%), but an increasing number (58%) indicated they also conduct retrospective, pre-bill queries, according to the 2010 Physician Query Benchmarking Report.

“It shows there are multiple stages to documentation improvement,” says Gloryanne Bryant, RHIA, CCS, CCDS, regional managing director of HIM (NCAL revenue cycle) for Kaiser Foundation Health Plan, Inc. & Hospitals in Oakland, CA. “To me, it also illustrates that there must be good collaboration between the CDI and health information management/ coding departments. CDI programs are not singularly focused on concurrent review anymore, and that is an interesting trend.”

The number of retrospective reviews was larger than expected for Donald A. Butler, RN, CCDS, CDI manager at Pitt County Memorial Hospital in Greenville, NC. Butler wonders what types of records constitute that 58%: Were they short-stay discharges which CDI staff were unable to examine while the patient was still in the hospital, or are CDI staff increasingly handling all query types regardless of where the record sits in the billing cycle?

However, 62% of respondents indicated that the HIM/coding department follows up on/closes out post- discharge queries, which raises concerns for Butler.

“Is this a perceived best practice or a reflection of traditional divisions of labor and facility structure?” he asks. At some facilities, CDI staff is responsible for initiating queries while HIM/coding staff maintain responsibility for query follow-up, says Gail B. Marini, RN, MM, CCS, LNC, CDI manager at South Shore Hospital in Weymouth, MA, and a member of the ACDIS advisory board.

Nevertheless, “I am amazed that the majority said their queries are not closed out by CDI specialists,” Marini says.

“It raises some additional questions for me,” says Butler. “Is there a lack of agreement between CDI and HIM, or a lack of ownership of the query process? If there are a large number of queries not resolved prior to discharge, what does that say about the CDI department’s efforts?”

Bryant, however, thinks that the responses indicate a collaborative approach to documentation improvement—that when CDI cannot clear the record prior to discharge, HIM/coding staff are willing and able to step in and continue the query process.

“I think it goes back to both departments need[ing] to be engaged in the process and willing to work together to ensure the completeness of the medical record,” Bryant says.


A query poem to wake up your program

It is National Poetry Month, after all.

Query in the morning
Query after lunch
Query in the evening
‘Cause I have a strong hunch

Query for anemia
Query for a link
Query for a coma
It makes the doctor think

Query for the failure
Query for the cause
Query for pneumonia
There is no time to pause

Query for exacerbation
Query for TIA
Query for specific words
‘Cause they don’t know what to say

Query on computer
Query with a pen
Query all the more
When we change to ICD-10!

Tip: Update your program with compliance efforts

When evaluating overall compliance within a CDI department, managers should:

  • Review all payers. Although everyone has to start small when initiating a CDI program, your policy should state that your process is “across all payers” and then work toward that goal. You don’t want to create a perception that you are treating Medicare or Medicaid beneficiaries differently than other patients (doing so is a big “no-no” from the governments standpoint).
  • Query consistently, not just when it affects the DRG assignment. On review, it’s easy for someone to see when queries are only generated to “get more money.” If a query gets you less money (present on admission conditions, CC/MCCs), query anyway to ensure a complete medical health record. You want to establish a pattern of compliant practices. You want outside auditors to work extremely hard to identify recoupment issues.
  • Establish one query policy and procedure that covers everyone on the team.  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.
  • Establish internal auditing processes to analyze queries for compliance against your policy. And be sure to do these audits routinely. Keep records of such audits so you can prove everyone is consistently using the same process (just in case there’s trouble down the line). For example, we had a very scientific audit process at my facility—I gave mine to Mary, and Mary gave hers to Sue, Sue gave hers to me. We analyzed the format, wording, appropriateness of choices then performed random record reviews to validate the queries’ appropriateness.
  • Keep records of continuing coding and/or CDI education. It will show that your team is kept up-to-date with the latest information regarding compliant practices.

Editor’s Note: This article appeared in the December 23, 2010 edition of CDI Strategies.

Q&A: Searching for the principal diagnosis

Don't get sent to the principal's office for lack of principal diagnosis specificity.

Q: We had a patient come in for back pain and treatment for a possible neurological impingement. However, after a five-day stay, the physician documents neck mass and for the remainder of the stay the resources appear to have been focused on that treatment. How do I discern the principal diagnosis? Am I limited to the simple back pain or can the coder chose the neck mass?

A: UHDDS guidelines define the principal diagnosis as “the condition determined by the physician, after study, to be chiefly responsible for the patient’s admission to the hospital for care.” This particular question is somewhat difficult to answer, however, without the complete medical record as a reference. The actual documentation will ultimately determine the principal diagnosis.

The following are just a few questions raised by the scenario described:

  • What treatment was rendered?
  • Was there a definitive surgical procedure related to a particular diagnosis?
  • Are there secondary conditions present?
  • Paresis
  • Hemiparesis
  • Neuropathy
  • Neurogenic bowel / bladder
  • Foot drop
  • Other neuro condition
  • Did the problem seem more orthopedic or neurologic?  Those issues with spinal cord impairment typically go to neurologic conditions when coded, and those without spinal cord impairment typically code to orthopedic.

If the documentation clearly links the symptoms at admission (i.e., back pain) to the newly diagnosed neck mass, then you could assign a principal diagnosis code for the mass. From the information relayed here, there might also be an opportunity to further clarify the type of mass: Is it a malignant neoplasm or tumor of the spine? The principal diagnosis could be the newly identified mass, but the physician would need to clearly document the link, i.e., “back pain/neurologic dysfunction due to _____ neck mass (whatever the final pathologists’ report is).”

The key in this case is whether the physician establishes the clear linkage in the chart that the back pain has been found to be due to the neck mass.  If that is done, the neck mass would then be the appropriate principle diagnosis.  Otherwise, “back pain” is it and that would be unfortunate.  “The condition determined . . . after study” (the neck mass) is the principle diagnosis as long as the linkage to the presenting symptoms is there.

So, my advice is to look closely at what the notes say, otherwise you might be stuck with “back pain.”

Editor’s Note: Lynne Spryszak, RN, CPC-A, CDI Education Director for HCPro Inc., Danvers, MA, and Trey LaCharite, MD, UT Hospitalists, at the University of Tennessee in Knoxville Clachari@UTMCK.EDU answered this question.