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New sample query forms posted

Check out the latest sample query forms at

The American Hosptial Association Coding Clinic cites numerous instances where coders are instructed to query the physician so it is important that you have the tools to do so. That’s why ACDIS members graciously donate samples of their query forms for the association to post on the Forms & Tools Library.

The latest batch of queries comes from Susan A. Klein, BSN, RN, C-CDI, director of clinical documentation management at Saint Peter’s University Hospital in Monroe Township, NJ. Klein included query samples regarding:

  • staging for chronic renal failure
  • unspecified chest pain
  • congestive heart failure
  • debridement documentation

Although Klein expects to update her congestive heart failure form to include some core measures information in 2011 the sample provided does offer an interesting checklist of potential diagnoses that could increase the specificity of the medical record. Klein created the forms herself, based on her experiences in CDI and the documentation improvement program she implemented at SPUH. Each form was discussed at its respective medical division and approved by the facility forms committee and medical record committee for their approvals as well.

As with all the forms and other items included in the ACDIS Forms & Tools Library, Klein’s donations are intended as a sample only and any diagnostic criteria should meet the approval of your medical staff and compliance team. “As you know every hospital is unique,” says Klein. “This works well for us here.”

New Coding Clinic update available for download

Hello ACDIS members,

I’m pleased to tell you that the CDI Journal special supplement Coding Clinic Update is now available for download. This supplement provides critical updates on the second quarter 2010 AHA Coding Clinic for ICD-9-CM of which all CDI specialists should be aware.

The author of the supplement is James S. Kennedy, MD, CCS, managing director for FTI Healthcare.

This quarter’s issue  includes updates related to the use of cancer staging forms, BMI, and far-reaching issues surrounding the coding of gross hematuria due to prostate cancer.

ACDIS members can download the supplement here:

If you have any questions or comments, please feel free to leave them here or you can e-mail Dr. Kennedy directly. His e-mail address is located at the end of the document.



Q&A: Query the physician when multiple options are checked on form

Q: Our CDI specialists tend to ask questions that provide the physician with multiple options to choose from. It is not uncommon to have a query with multiple answers checked by the physician. A good example would be “What is the cause of the patient’s syncope?” Options for the cause of syncope given are cardiac arrhythmia, anemia, and other. The physician then chooses all options given and also writes in dementia.

In this case, would it be appropriate to choose any of the options as the principal diagnosis based on the following guideline: “Two or more diagnoses that equally meet the definition for principal diagnosis: In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first” ?

Or would it be more appropriate to code the syncope first followed by the chosen diagnoses based on the following guideline: “A symptom(s) followed by contrasting/comparative diagnoses: When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as additional diagnoses”?

A: As a CDI specialist, I always advise the physician, “don’t give us the symptomology. That shows you’re not using resources to treat the patient. Document what you’re thinking about the patient.”

For example, in the above situation for the patient admitted with syncope, query for the cause. If it was a suspected stroke and the ensuing clincial workup was negative, ask the physician to provide documentation along with supporting information (i.e., “carotid doppler shows no significant blockage, cause of syncope related to dehydration and slight orthostasis. Patient’s orthostatic changes and volume depletion responded nicely to fluid rescusitation, patient out in the hot sun all day with little to drink.”)

If the physician doesn’t know the diagnosis, than he or she doesn’t know. If syncope is reported on the discharge summary, then in above example the rule from the ICD-9-CM Official Guidelines for Coding and Reporting regarding a symptom followed by contrasting/comparative diagnoses would apply, and a coder must report syncope as the principal diagnosis. But CDI specialists should be looking to avoid these situations through an appropriate query.

This also feels like an issue with the query process and physician education. Linking a diagnosis to the symptom of syncope should be supported by medication changes, treatment plans, or medical intervention. Checking off several diagnoses offered on the query (including other) is a clarification opportunity with the physician, not a coding guideline issue.

Reduce RAC Vulnerabilities with a Quality CDI Program

DRG (diagnosis-related groups) validation issues have been the main target of RAC (recovery audit coordinators) nationwide in recent months. When unclear documentation results in improperly assigned DRGs, it puts facilities at risk for RAC denials. However, an effective clinical documentation improvement (CDI) program aims to minimize these financial risks by producing the most accurate and comprehensive medical records possible—records that fully support the condition of the patient and the services rendered.

A CDI specialist is trained to identify terms and phrases that a physician uses that may lead to the assignment of imprecise or non-specific codes, according to Lynne Spryszak, RN, CCDS, CPC-A, CDI Education Director for HCPro, Inc.

The CDI program’s connection to the RAC process runs deep. When the documentation in the record does not match the services administered, the provider may see a RAC denial that could have been prevented with a sound CDI program. Spryszak offers the diagnosis of urosepsis as an example.

“While going through medical school students learn that urosepsis is an overwhelming infection that started in the patient’s urinary system, which indicates a very sick patient,” says Spryszak. “However, in the coding world, the term urosepsis equates to a simple urinary tract infection.”

Enter the RAC, who, when reviewing a case which grouped to MS-DRG 872—Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours without MCC—notices that the patient had a short stay and received only one antibiotic. When reviewing from a retrospective audit point of view, this would be a likely indication that the resources given to the patient were typical of treating a urinary tract infection, as opposed to the higher severity sepsis case which coincidentally carries a higher paying reimbursement. A RAC would evaluate this and likely perceive it as an invalid DRG assignment and thus deny it, according to Spryszak.

“A good quality documentation improvement program that focuses on not only supporting the DRG assignment but also focuses on clarifying all conditions that are imprecise will better support the record from a compliance standpoint,” she says. “If you have a complete, precise medical record, it should be able to stand up to audit.”

Through the years, however, some have suggested that CDI specialists submit too many “leading questions” in their query forms and requests which may sway the physician’s decision one way or the other, according to Spryszak. The definition of “leading” has been the subject of much dispute. As a result, the American Health Information Management Association (AHIMA) published it Guidance for Clinical Documentation Programs to help outline what would constitute a “leading query” versus a compliant query.

Spryszak refers back to the example of sepsis vs. urosepsis to provide an example of the physician query’s impact on both the CDI program and facilities’ vulnerability to RACS.

“If a higher than normal percentage of patients in a facility are being coded to sepsis instead of just a urinary tract infection, it may be because the processes involved,” she says. “A review of these cases may show that the final DRG assignments were the result of asking leading questions.”

When it comes to RAC audits and denials, every part of the process matters; but when you have a thorough, compliance-based CDI program in place, it puts a facility in that much better of a position to defend against them.

Editor’s Note: This article was written by James Carroll, for HealthLeaders Media, sister publication to the ACDIS, on June 17, 2010. Read more about what individual CDI specialists are experiencing in terms of RAC reviews and RAC requests for physician query documentation in the July edition of the CDI Journal.

Coding Clinic first quarter 2010 supplement to April CDI Journal now available

Hi ACDIS members, I thought you’d like to know that our quarterly Coding Clinic for ICD-9-CM special supplement to CDI Journal is now available for download.

James Kennedy, MD, CCS, of FTI Consulting and a member of the ACDIS advisory board provides the latest breakdown of important developments in the First Quarter 2010 issue of Coding Clinic, focusing in particular on issues relevant to CDI. Note that there are some important documentation and coding changes to COPD, stroke, SIRS, and more in this issue.

As a reminder, this supplement is a members-only benefit which can be accessed here on the CDI Journal home page .

We hope you find these special supplements of value, and if you have any comments or questions for Dr. Kennedy you may post them here.

Take care,


Paper vs. patient

Recent CDI related-headlines consist primarily of complaints regarding the burden of paperwork on patient care and the cost of healthcare.

A study published in April in BMC Health Services Research found that “the total time for communication with patients and their relatives was 85 minutes per physician per day” which averaged out at a little more than four minutes per patient.

The study, conducted at the University Medical Center Freiburg, a 1,700-bed academic hospital in Germany, observed physician behavior for all its 34 wards across 15 different medical departments. In all, study organizers analyzed 374 working hours. Physicians’ discussions with their colleagues took the most time, roughly 150 minutes on average, while documentation and administrative takes earned second place sucking up an average of 148 minutes a day. Interestingly, however, the physicians themselves thought they communicated with patients twice as long as the study findings suggested.

The study results may add credence to a New York Times Blog post written by Pauline W. Chen, MD. Chen pulls  a snippet from Lemony Snicket, the children’s book series — a snippet which chastises the children heroes for not knowing that paperwork is the most important product produced by a hospital.

Chen cites a Mayo Clinic study which states of 67.9% of residents who reported spending in excess of four hours a day on documentation, only 38.9% reported spending this amount of time in direct patient contact. The report, “Time Spent on Clinical Documentation: A Survey of Internal Medicine Residents and Program Directors” was published in the February issue of the Archives of Internal Medicine.

Chen isn’t the only physician lamenting documentation burdens. C. L. Gray, MD, president of Physicians for Reform, wrote in a Fox News Blog that overhead costs such as billing and administrative assistance “consumes 60% of the average physician’s collections… Trapped under mountains of paperwork and handcuffed to inefficient billing and collection systems, the average medical practice must hire four support staff for every working physician,” Gray wrote.

The AHIMA CDI practice brief: A Q&A discussion with co-chair Gloryanne Bryant

A CDI Work Group run by the American Health Information Management Association (AHIMA) has been meeting for more than a year to address and develop CDI resources and tools. One of the primary objectives of the AHIMA CDI Work Group was the development of a CDI practice brief. The CDI practice brief is expected to provide additional support and enhancements to the previously published practice brief titled Managing an Effective Query Process, which serves as a recommended industry best practice for CDI programs.

ACDIS Advisory Board member Gloryanne Bryant, RHIA, CCS, CCDS, Regional Managing Director of HIM (NCAL Revenue Cycle) for Kaiser Foundation Health Plan Inc. & Hospitals in Oakland, CA, was co-chair of AHIMA CDI Work Group. She recently talked with ACDIS Director Brian Murphy about this important project. A transcript of their Q&A session appeared in last week’s issue of CDI Strategies.

An Irish documentation tale

The CDI leprechaun is a type of fairy in Irish folklore. He or she usually takes the form of an old nurse, clad in a white lab coat, who enjoys partaking in helpful mischief.  The earliest known reference to the CDI leprechaun appears in the medieval tale the Adventure of Doctor Son of Kildare.

Follow the CDI lebrechauns to documentation gold!

The story contains an episode in which doctor falls asleep in the physicians lounge and wakes up to find himself being dragged onto the ward by three luchorpain, or leprechauns. He turns the tables on them and captures his abductors, who grant him three wishes in exchange for their release. The doctor chooses to document better, increase his severity of illness scores and of course, to help his hospital prosper financially. His wishes are granted and the three CDI leprechauns retreated down the hospital corridors.

The CDI leprechaun is a solitary creature whose principal occupation is reviewing charts and improving documentation. The leprechaun can be a practical joker, often leaving queries with obscure riddles such as “the patient has an albumin of 1.5; please document the diagnosis this may represent.”

As well as chart reviews, the CDI leprechaun’s other trade is comorbidity banking. The wealth of these fairies comes from their knowledge of CC’s and MCC’s, which they have printed onto secret pocket cards. Rainbows reveal where the cards are hidden, so a CDI leprechaun will often spend all day reviewing charts throughout the hospital to elude the telltale end of the rainbow.  If you catch a leprechaun, don’t let him or her out of your grasp, for he or she will quickly dash out of your sight.

No one has actually ever caught a leprechaun, but the pocket cards are now free for the asking, since the CDI leprechauns have a heart of gold and a desire to help others.  Physicians need only ask, and the smiling documentation fairy will assist with any wording needs.

Good luck to all and Happy St. Patrick’s day.

Coding Clinic guidance can help with surgical complication documentation

During the November 20, 2009 ACDIS audio conference “Surgical Complications: Clinical Documentation Improvement for Compliant Coding and Accurate Quality Measures”  speakers Robert S. Gold, MD and Lena N. Wilson, MHI, RHIA, CCS, provided a list of Coding Clinic references they thought could be helpful to others. The list includes:

  • Care during surgery: 3rd quarter, 1990
  • Accidental puncture laceration: 2nd quarter, 2007 and 3rd quarter, 1994
  • GI complication code: 3rd quarter, 2003; 4th quarter, 1995; and 3rd quarter, 1995
  • Adhesion code: 3rd quarter, 2003; 4th quarter, 1995; 3rd quarter, 1995; and Sep-Oct, 1985

The program includes a case study from Clarian Health Partners in Indianapolis and illustrates how documentation affects surgeons and their public profiles.  During the program Dr. Gold offers guidelines for reporting surgery complications and explains the disconnect between a hospital’s financial considerations and the physician’s profile.

If you didn’t get a chance to listen to the program, you can purchase an audio-on-demand version from

Create a CDI program ‘vision’

Start your query development by establishing a clear vision.

Editor’s note: The following is an excerpt from the Physician Queries Handbook: Guide to Compliant and Effective Communication.

As the saying goes: you can’t see without strong vision. So, before you build your CDI program or start to establish a physician query process determine the scope, vision, and mission of your facility’s efforts. Early in CDI program implementation, consider the creation of a steering committee that works together to write a vision statement for the CDI program.

In its simplest form, the vision of a CDI program should be precise and accurate clinical documentation that results in appropriate coding, assignment of diagnosis-related groups (DRGs), quality measures, and reimbursement.

Make sure the vision of your program and query process supports the desires of the various facility departments CDI supports. By ensuring that members understand the vision for the program, the role their department plays, and the inter dependencies of their roles, you help everyone involved feel a sense of ownership int eh program and its accomplishments.