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 HCMarketplace.com
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.
Hi ACDIS members, if you go to our CDI Journal home page you will find a special supplement to the January 2010 issue: A special report reviewing the important developments and guidance in Coding Clinic for ICD-9-CM, fourth quarter 2009. The sources of the report are James Kennedy, MD, CCS, director of FTI Healthcare consulting and author of the Physician Queries Handbook, and Laura Doty, RHIT, a director at FTI Healthcare.
This special report breaks down the latest Coding Clinic as it pertains to CDI specialists. This quarter of Coding Clinic features an added emphasis on documentation at the time of discharge, CDI opportunities in diabetic patients, and changes to coding and reporting of obstetrics patients.
Coding Clinic for ICD-9-CM is a vital component of every CDI specialists’ toolbox, and we hope you find the article useful. If you have any feedback for Dr. Kennedy or Laura, please feel free to post it right here.
CDI specialists and HIM professionals may often wish they could read physicians’ minds when clinical documentation is lacking, but this superhuman power seems to exist only in books and movies. However, most coders probably would agree that the ability to read minds would be enormously helpful when deciding whether to report uncertain diagnoses. These are conditions for which physicians find clinical evidence that leads to a suspicion but not a definitive diagnosis.
The challenge for coders is that uncertain diagnoses often change or morph into something else during the hospital stay and doctors don’t do a good job of telling us whether it’s ruled out. They change their thought process in the management of the patient and go down another path.
Complex clinical scenarios and inconsistent physician documentation complicate matters. When initial documentation includes an uncertain diagnosis—but the physician does not include that same diagnosis in the discharge summary—a query may be necessary. Herein lies the confusion.
If you want to be 100% certain, then you’re going to be querying for everything. Instead, CDI specialists need to use their best clinical knowledge to determine when a query is truly necessary.
For example, consider the following scenario:
A patient who recently suffered a heart attack presents to the cardiac care unit with shortness of breath. The physician conducts a thorough history and physical, documents a plan of care, starts the patient on IV Lasix, orders a chest x-ray, and documents ‘possible acute congestive heart failure (CHF).’
Clinical notes indicate that during the second day of the hospital stay, the physician stops the Lasix with no orders for step-down therapy to oral Lasix. A review of the physician orders indicates no further management of acute CHF with commonly prescribed CHF treatment regimens (e.g., other types of diuretics, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, beta blockers, or digoxin).
Upon discharge, there is no mention of acute CHF, and the patient is not given any meds to manage acute CHF.
This is a perfect example of a scenario in which CDI specialists can employ their basic clinical knowledge and avoid a potentially needless query. One day of IV Lasix treatment without patient management may not be considered the standard of care for treatment for acute CHF.
Let’s do our homework before we query. When CDI specialists or coders send unnecessary queries, they begin to lose physicians’ respect.
When I was a little girl, I wanted a turbo-slingshot in the worst kind of way. I told every department
store Santa about my secret wish. When Christmas morning came I was heartbroken when the slingshot was not included in my bounty of dolls, clothes, and games. I now realize that perhaps I had told the wrong person. In my embarrassment over the desire to receive a non traditional gift, I failed to tell my mother about the coveted slingshot.
The same is also true of queries. If we ask the wrong person, we will not always get the answer we are seeking. Likewise if we ask the wrong question or an inappropriately worded question, the physician may get confused and ignore the request.
One of my colleagues shared with me a conversation she had with a young resident physician. She left a query asking the doctor if there was a link between a patients’ UTI and their chronic Foley use. She also needed him to document that the UTI was present at the time of admission. The physician was absolutely flummoxed. The query read: “Please state in progress notes what diagnosis the urinalysis report indicates, and if the condition is secondary to chronic Foley use and if present on admission.”
She talked to him the next day and he asked her to explain the unusual request. He told her that the query left him feeling unsure of what was wanted. She explained the hospitals strict policy regarding the wording of queries and the avoidance of leading questions. She carefully went over the patient record and pointed out where the communication breakdown had occurred.
The physician had documented the patient had presented to the emergency room from a nursing home with a Foley catheter in place. He ordered a urinalysis with culture. When the results were obtained a day later, he had simply written U/A positive, start on Levaquin. My clever coworker explained to him that the “U/A positive” documentation could not be picked up by the coders and therefore it was unclear why the patient had been admitted. Furthermore, a link to the chronic Foley with the UTI and the present on admission status were not established in the documentation.
He responded with an enthusiastic “Aha!!” He finally understood. She had asked the right person, the right question, in the right manner.
Now, if I could only get Santa to bring me a laptop for Christmas…
I hope my husband sees the large picture I pasted on the refrigerator with my letter to Santa and an attached query form. “Dear Santa, Please clarify if the above person was a good girl this year and if so, buy her this computer or else!”
A bit leading perhaps, but I will not make the same mistake again. Merry Christmas, Documentation Specialists!
I often search the World Wide Web for information pertinent to clinical documentation improvement specialists. Quite often I find comments similar the ones posted Sunday, November 29, in The Washington Times by Jason D. Fodeman, MD, an internal medicine resident at the University of Connecticut, a former health policy fellow at the Heritage Foundation.
In his opinion piece “Defensive medicine costs: Litigation-inspired tests hinder needed ones,” Fodeman suggests documentation improvement directives stem from burdensome malpractice litigation, insurance requirements, and physicians’ lawsuit fears. He argues that documentation efforts take time away from patient care. He writes:
“Primarily this degree of documentation is done out of necessity to keep the pesky lawyers at bay. In fact, by wasting valuable physician time that could be better spent actually seeing patients, it can be counterproductive to a patient’s well-being.”
CDI specialists attempt to overcome such physician perspectives every day. You know improved physician documentation isn’t just about dollars, and it’s not a feigned attempt to reduce medical errors. Complete and accurate documentation improves patient care by affording every healthcare provider with the most complete documenation of a specific patient’s treatment.
While the increased pressure to provide complete documentation may indeed have a tenticle or two stretching from the governmental policy monsters and malpractice boogeymen such criticism of documentation improvement efforts drastically oversimplify an extremely complex healthcare system. One increasingly proven way to shed light on that system is through the education efforts CDI professionals offer hospital physicians daily.
Keep up the good work. Write on.
An ACDIS member recently recounted a disappointing story regarding her facility CDI program implementation. Essentially, the nurses performing concurrent queries disagreed with the coders at nearly every turn. I’m sure many of you can relate to this predicament. In the end, the facility brought its lawyer and compliance officer to the table. A good move which maybe might have saved some aggrevation if they’d been at the table from the beginning.
The coding rules and regulations are strict and too often seem to conflict with clinical common sense. RNs believe they’re perfectly entitled to ask a physican a basic question regarding patient information in the chart regardless of whether the question may be construed as “leading” by outside auditors.
So I thought it might be a good idea to post a short excerpt from the article Establish physician query protocols to resolve compliance risks in the July 2009 issue of the CDI Journal. In the article Andrei M. Costantino, MHA, CHC, CPC-H, CPC, director of organizational integrity at Trinity Health in Farmington Hill, MI, Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta, and Robert A. Wade, Esq., a healthcare attorney at Baker & Daniels, in South Bend, IN, offer tools to help keep CDI programs compliant with government rules and regulations.
Creating policies and procedures for your query processes is one way to help eliminate risk. Legal penalties for filing false claims due to leading physician queries won’t seem like a misdemeanor if the Office of Inspector General and the U.S. Department of Justice (DOJ) investigate. The CDI program could unduly influence physician documentation. Such influence could in turn cause compliance headaches or, worse, a False Claims Act lawsuit.
Creating policies and procedures for your query processes is one way to help eliminate risk. It’s also the reason many experienced CDI administrators know their compliance officer and legal counsel, and it’s also why new program leaders should introduce themselves to the compliance department as soon as possible, says Costantino.
The CDI Journal is the quarterly publication of the Association of Clinical Documentation Improvement Specialists (ACDIS) and is free for its membership. To become a member contact Sue Calabro at firstname.lastname@example.org or call 877/240-6586
There’s still time to sign up for Friday’s (November 20, 1 p.m. EST) audio conference: Surgical Complications: Clinical Documentation Improvement for Compliant Coding and Accurate Quality Measures with Robert S. Gold, MD, and Lena N. Wilson, RHIA, CCS.
Wilson is the HIM operations manager of the clinical documentation improvement program (CDIP) and inpatient coding at Clarian Health Partners in Indianapolis. In her current role, Wilson is responsible for the CDI program at Clarian’s three facilities in downtown Indianapolis, and the inpatient coding operations for the downtown facilities and the two suburban hospitals.
And while many in the CDI world think that Dr. Gold requires no introduction, let me nevertheless tout his expertise as founder and CEO of DCBA, Inc., in Atlanta, GA, a consulting firm that provides physician-to-physician education programs in clinical documentation improvement. He has more than 42 years of experience as a physician, medical director, and consultant.
Surgery documentation is an area rife with concern from both the physician point-of-view as well as from the CDI and coding perspective, like Dr. Gold points out in this Friday’s presentation. Too often CDI programs improve a facility’s risk adjusted mortality index but negatively impact a surgeon’s physician profile. Such outcomes make it difficult to get physician support for CDI. He outlines the following three “Golden Rules:”
- If it is a complication of surgery, it is either a complication or surgery
- If it is a manifestation of a disease unrelated to the surgery it is not a complication of the surgery
- If it is not treated it may not be codable—but it may
Altered mental status, dementia, or encephalopathy: What’s really going on with your elderly patient that presents with confusion?
The typical scenario is the elderly patient with some minor dementia, who has been living fairly independently, who is described as being more confused than usual. A work up does not indicate any acute neurological conditions but the patient is admitted with altered mental status. Further work up often reveals an underlying infection or metabolic condition. After treatment of the underlying concern, the patient’s mental status returns to baseline and the patient is discharged back to their usual living arrangements.
The resources consumed in treating this type of patient often include a head CT, neurological consult, neurological checks, EEG, sometimes even a bed in the intensive care unit. But if the physician only documents altered mental status or dementia and not a type of encephalopathy, the true severity of illness of the patient may not be accurately reflected.
So what is encephalopathy?
As defined by the National Institute of Neurological Disorders and Strokes, National Institutes of Health, encephalopathy is a term for any diffuse disease of the brain that alters brain function or structure. Encephalopathy may be caused by an infectious agent, metabolic dysfunction, brain tumor or increased pressure in the skull, prolonged exposure to toxic elements (including solvents, drugs, radiation) chronic progressive trauma, poor nutrition, or any reason for lack of oxygen or blood flow to the brain.
The hallmark of encephalopathy is an altered mental state. Depending on the type and severity of encephalopathy, common neurological symptoms are progressive loss of memory and cognitive ability, subtle personality changes, inability to concentrate, lethargy, and progressive loss of consciousness. Other neurological symptoms may include tremors, muscle atrophy and weakness, dementia, seizures, and loss of ability to swallow or speak.
Coding Clinic provided a definition in the first quarter of 1988 (pages 3-4):
Clinical documentation improvement specialists continue to have trouble discerning between leading and non-leading physician queries. The question often comes down to an understanding of the various previous “lives” of professionals. Nurses are used parrying over clinical decision making, so why should their queries regarding documentation be any different from the clinical questions they’re used to asking? Quite simply: because there’s money involved.
Sure it’s true just as Robert S. Gold, MD, founder of DCBA, Inc., in Atlanta, said in his
article “Is asking for clarification ‘leading’?” that the government never clearly defined the term “leading” and many experts continue to banter over the logistics of the language. However, CDI specialists need to shine a bright light on the differences between the leading and non-leading query to protect themselves and their facilities from the coming onslaught of government auditing agencies.
While the likelihood of true healthcare reform legislation seems to be dwindling, President Barack Obama nevertheless continues to push against apparent payment abuses throughout the system. CDI professionals are meant to be a facility’s first line of defense against such abuses. It a CDI specialist’s job to make sure what was documented in the patient’s medical record is the most accurate description of the care the patient received.
Yet we still hear of facilities focused on Medicare only patients. We still hear about CDI programs directed to only look at records of a certain dollar value. We still hear tales of CDI professionals requesting specific language from physician simply due to some administratively imposed financial quota.
Inappropriate, leading queries, not only open your facility to an inordinate amount of risk but also jeopardize patient care. Generate policies and procedures for your facility that outlines the purpose and intent of your CDI program. Include your administrators, HIM leaders, physician liaisons, and compliance officers in the process. Create standard query forms that allow for the physician to further explain his or her documentation and even to disagree with the reason for the query.
For more information about physician query best practices and the legal architecture on which current query practice is based, read the Physicians Queries Handbook.