Q: Is it is okay to alter, add to, or take back a query form after the physician answers it?
A: As a CDI specialist your role is to construct a query when there is evidence of an incomplete, vague, or missing diagnosis based on clinical indicators in the medical record. Your query needs to be as accurate as possible at the point it is issued based on the facts/clinical indicators available. If there are not enough facts/clinical indicators then a query should not be issued.
If the provider disagrees that an additional diagnosis is required based on the initial query and presented clinical indicators, close the query and document that the provider responded and disagreed. Altering or adding clinical indicators to the query at this point could be considered prodding the provider to convince him/her to add a diagnosis.
Additionally, a query should not force the provider to document a particular diagnosis. Typically, queries are maintained to ensure that:
- a query was issued if the health record was unclear
- the CDI specialist was not on a “fishing expedition”
- the query format allowed the provider to independently assign the applicable diagnosis
My recommendation is to refer to AHIMA’s query practice briefs related to the query process and what standards should be used when constructing a query.
Typically, once a query is placed on the record is it not altered by the CDI specialist. Instead, a new query can be issued if needed. The impact of the query is usually recorded elsewhere in a CDI tracking database. Most CDI departments monitor queries to determine if there was
- a response
- agreement with the query
- an effect on the claim
As such if a query becomes invalid that is recorded in the CDI review worksheet or database where there should be an option to mark the query as “not applicable,” but the query itself would remain in the health record if that is the policy of the organization.
All organizations must define the elements of their legal medical record. Your CDI program/organization should determine whether to keep queries as a permanent part of the medical record or whether it removes the queries to file and track them elsewhere. A record isn’t typically closed/finalized until the discharge summary is signed by the attending provider, who has up to 30 days to complete the record according to the Joint Commission and CMS regulation. Once the medical record is closed/finalized the only way to change the record is to add an addendum or late entry. Elements of the health record should never be removed.
If your facility’s policy is for the provider to respond to the query on the query form itself, then I definitely would never alter the query form. It is important to note, however, that in its query guidances, AHIMA does not endorse the use of a query format where the provider only signs a query form to add the diagnosis to the medical record. AHIMA encourages physicians to supply their responses directly into the medical record as appropriate.
If you issue a verbal query, a written testament to that query should accurately reflect the conversation with the provider. There would be few, if any, reasons to alter a query under these circumstances.
In March 2011, the ICD-9-CM Coordination and Maintenance Committee updated the following code definitions and exclusions:
- 518.5: Pulmonary insufficiency following trauma and surgery
- 518.51: Acute respiratory failure following trauma and surgery
- Respiratory failure, not otherwise specified, following trauma and surgery
- 518.52: Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery
- Adult respiratory distress syndrome (ARDS)
- Pulmonary insufficiency following surgery
- Pulmonary insufficiency following trauma
- Shock lung related to trauma and surgery
- 518.53: Acute and chronic respiratory failure following trauma and surgery
- Excludes: acute and chronic respiratory failure in other conditions (518.84)
- 518.8: Other diseases of lung
- 518.81: Acute respiratory failure
- Excludes: acute respiratory failure following trauma and surgery (518.51)
- 518.82: Other pulmonary insufficiency, not elsewhere classified
- Excludes: acute interstitial pneumonitis (516.33) ARDS associated with trauma or surgery (518.52) pulmonary insufficiency following trauma or surgery (518.52)
- 518.84: Acute and chronic respiratory failure
- Excludes: acute and chronic respiratory failure following trauma
I’d like to discuss some of the limitations and challenges of these codes and their current descriptions.
Postoperative and post-traumatic respiratory failure
ICD-9-CM codes 518.5–518.53 include the description “following trauma and surgery.” Combining trauma and surgery into one code is inappropriate. Patients with trauma, lung contusion, or bilateral traumatic pneumothoraces or hemothoraces will develop post-traumatic respiratory failure. The same is true for patients with crushed tracheas. These patients are distinctly different from those with postoperative respiratory failure. Each group should be tracked differently; therefore, they should be coded differently too.
Research is impeded by not coding and tracking each group separately. That’s because even when a patient experiences trauma, surgery may be the actual cause of the postoperative respiratory failure. The POA indicator does not help clarify the cause of post-traumatic respiratory failure because respiratory failure may or may not exist on admission. [more]
Determining when to code a post-surgical complication as opposed to simply considering it to be an expected outcome after surgery can be a complicated task.
A complication is “a condition that occurred after admission that, because of its presence with a specific principal diagnosis, would cause an increase in the length of stay by at least one day in at least 75% of the patients,” according to CMS.
Therefore documentation of a postoperative condition does not necessarily indicate that there is a link between the condition and the surgery, according to Audrey G. Howard, RHIA, senior consultant for 3M Health Information Systems in Atlanta, who will join Cheryl Manchenton, RN, BSN, an inpatient consultant for 3M Health Information System on Thursday, July 12, for a live audio conference “Inpatient Postoperative Complications: Resolve your facility’s documentation and coding concerns.”
For a condition to be considered a postoperative complication all of the following must be true:
- It must be more than a routinely expected condition or occurrence, and there should be evidence that the provider was evaluating, monitoring, or treating the condition
- There must be a cause and effect relationship between the care provided and the condition
- Physician documentation must indicate that the condition is a complication
According to Coding Clinic, Third Quarter, 2009, p.5, “If the physician does not explicitly document whether the condition is a complication of the procedure, then the physician should be queried for clarification.”
Coding Clinic, First Quarter, 2011, pp. 13–14 further emphasizes this point and clarifies that it is the physician’s responsibility to distinguish a condition as a complication, stating that “only a physician can diagnose a condition, and the physician must explicitly document whether the condition is a complication.”
For example, a physician may document a “postoperative ileus,” but it is very common for a patient to have an ileus after surgery, Howard says. Therefore, this alone does not qualify as a postoperative complication.
“If nothing is being evaluated, monitored, [or] treated, increasing nursing care, or increasing the patient’s length of stay, I would not pick up that postop ileus as a secondary diagnosis even though it was documented by the physician,” Howard says.
Editor’s Note: This article first published on JustCoding.com.
Editor’s Note: During last Thursday’s ACDIS Membership Quarterly Conference Call the Advisory Board discussed documentation requirements for post-operative respiratory failure and post-op pulmonary insufficiency among other topics. These calls, which are free to ACDIS members, allow participants to pose a question and gain feedback and perspective from the Board and other peers. Typically, upwards of 200 people join the call.
The following post was submitted by Janie Brown, RN, CDI specialist, at The Indiana Heart Hospital in Indianapolis. Contact her at JBrown5@ecommunity.com.
ACDIS members can download a recording of this and all previous, archived editions of the call from the ACDIS website.
When I started the CDI program here at The Indiana Heart Hospital (TIHH) nearly two years ago, I was also looking for some direction regarding how to document and code for respiratory failure/post-operative pulmonary insufficiency. For me, the AHA’s Coding Clinic for ICD-9-CM guidelines were unclear. So, I worked with our pulmonary critical care physician, Franklin Roesner, MD, one of our cardiac surgeons Bob Shoemaker, MD, and our Senior Medical Records Coder Debbie Dinsmore, to develop some internal guidelines for the use of the diagnosis of post-op pulmonary insufficiency. The definition we used is “a decrease in normal pulmonary function due to trauma to the thoracic cavity and or surgical intervention.”
The guidelines we ask our physicians to consider are as follows:
- Has pulmonary/critical care medicine been consulted?
- Has the patient experienced increased oxygen requirements over time?
- Has the patient required frequent respiratory treatments over and above incentive spirometry more than 24 hours post-op?
- Are chest x-rays being frequently monitored?
- Are pleural effusions being monitored or treated?
I have been known to “swoop” down to the SICU when I see a nephrologists typing in “respiratory failure” on a post-op emergent cardiac surgery who remains on the vent at 0800 after returning from the operating room at 0300 to just gently say, “are you sure you want to say that?”
We are very aware of the dangers of overusing this diagnosis here at TIHH and I think the development of our own internal guidelines has greatly assisted us in staying on the straight and narrow. We do not tend to include this diagnosis unless respiratory issues continue to greatly affect the patient’s progress on post-op day three or four.
In reference to using all electronic medical records: TIHH is the only hospital in our network that is all electronic. When I started here, our training consisted of learning to leave paper queries. I had no place to leave a paper, so I was forced to talk to my physicians. That turned out to be the biggest blessing in disguise I have probably ever experienced.
In my opinion, whether you are using paper or a computer for documentation, there is absolutely no substitute for the face-to-face exchange of thoughts and information when seeking to attain accuracy and completeness in the medical record. My advice to any CDI specialist is to get out of the office and away from the desk and talk to your physicians face-to-face.
Many novice CDI specialists do not readily identify when a diagnosis needs clarification. The following list is intended to serve a gentle reminder to “dig deeper.” Here is a list of “clue” words to help you identify when a query may be needed for clarification or specificity.
AMS needs clarification as to possible Acute Confusional State, Alzheimer’s Dementia, or Alzheimer’s with Behavioral Disturbance. If with associated Infection, metabolic condition, etc. it could also indicate Encephalopathy.
Urosepsis could be UTI or Sepsis secondary to UTI.
Hypoxemia/Respiratory Insufficiency could indicate a diagnosis of Acute Respiratory Failure or Acute post Operative Respiratory Insufficiency if the indicators are present. (E.g. Use of C-pap or Non re-breather mask, or O2 saturation less than 92%).
Anemia requires specificity of Chronic Anemia, Acute Blood Loss Anemia, Aplastic Anemia, etc.
Renal insufficiency/chronic kidney disease (CKD) requires added specificity for the stage of the CKD, the Creatinine baseline and further specificity as to possible Acute Renal Failure (ARF), and if indicators present (E.g. nephrotoxic medication usage) ARF with Tubular Necrosis.
FTT, Anorexia may indicate Malnutrition. If present, further specify as to whether it is mild, moderate, or severe.
CHF requires specificity of acute or chronic and systolic or diastolic heart failure.
Right/left sided weakness may indicate a diagnosis of hemiplegia or hemiparesis.
Problems with speech post CVA may indicate a diagnosis of Aphasia.
Drug use History requires clarification of use or abuse and if the Drug Use/Abuse is Ongoing.
Abdominal pain requires documentation of an underlying diagnosis. (E.g. Ulcer, Acute Pancreatitis, etc)
Chest pain requires documentation of an underlying diagnosis. (E.g. CAD, Angina, Costochondritis, etc.)
Gangrene-requires further specificity as to “Wet” infectious or “Dry” ischemic Gangrene
Poorly controlled Diabetes needs clarification whether Uncontrolled or Controlled Diabetes Mellitus.
Hypertensive Emergency needs clarification as to Malignant or Accelerated Hypertension.
DVT needs clarification as to Deep Vein Thrombosis or Thrombophelbitis.
I&D needs clarification as to whether this means Irrigation and Drainage, Exisional Debridement or Non Exisional debridement. (If exisional debridement performed then documentation must state if scalpel was used, clear margins obtained, and depth up to and including deepest layer.)
↓↑Na is not a diagnosis. Documentation must be obtained as to possible Hyper/ Hyponatremia.
I recently had occasion to stop and think about how I approach a chart for a clinical documentation review. For me, it has become an almost instinctual process, so I found it instructive to examine my process in a more systematic manner. With that in mind, I thought I would share my perspective on how to approach a review.
I recommend a review methodology that goes from door-to-door: beginning with the ED record and ending with the discharge summary. As you review the chart, think about the disease processes you see. If you are an RN CDI professional, think about this just as if you were taking care of that patient on the nursing unit. Consider how these disease processes interrelate and affect that patient’s care. Now you need to make that clinical picture fit the regulatory requirements through compliant, codeable language.
Step 1: Review the ED physician record. Note presenting signs and symptoms, lab values, medical history, and the ED physician’s impression, as well as the reason why the patient is being admitted. Note any diagnostics or procedures performed in the ED. Don’t forget this part of the admission, because you might be using the ED record as the basis for an attending query, such as acute respiratory failure for a dyspneic patient intubated in the ED.
Step 2: Look for the physician’s document of the patient’s history and physical (H&P). Use the same review strategy you used for the ED record. Determine if the physician has a clear idea of the principal diagnosis. Identify if the physician is waiting for additional diagnostics or consults. Take note of any gaps in the documentation. Can each diagnosis be coded completely based on the documentation? How firm is each diagnosis—are there diagnoses that are noted as rule out, probable, possible, cannot confirm, etc.?
Make note of those diagnoses so that you can follow the progression of each diagnosis as the patient receives inpatient care. You don’t want a diagnosis to drop off without resolution. Ensure that there is enough clinical information in the chart at this point to support the diagnoses the physician chose. With an understanding of how principal diagnosis is determined, what do you think the principal diagnosis is at this (albeit early) point? Also identify any early, potentially relevant secondary diagnoses. If the H&P is missing, make yourself a note to keep looking for it. If consults have been ordered, or you are expecting a consult to be ordered, make a note to look for the reports. Do you see a clinical picture without a diagnosis that might require a query?
Tip: Remember that when the chart is coded, the H&P and the discharge summary are going to carry the most weight.
Step 3: Look at vital signs and intake and output (I&O). Vital signs can give a strong clue in many cases as to just how sick your patient might be. You definitely need to note abnormals. I&O can help you if you’re looking for signs of acute renal failure due to dehydration, for instance. Determine if there are there any clinical conditions you might associate with the abnormal vital signs, such as a post-operative fever. Do you have enough supporting documentation to ask the physician if he or she suspects clinically significant atelectasis? Remember that when you evaluate for sepsis, fever is one of your SIRS indicators.
Step 4: Review labs and radiology reports. If there are abnormal findings, consider the clinical significance of those findings for the patient’s care. If the physician hasn’t addressed the abnormal findings in his or her documentation, make a note of those findings and follow the patient’s progression in future tests. As a CDI specialist, you may note a clinical progression based on those test results. Coders cannot code directly from labs or radiology reports, so if there is evidence of something clinically significant to report, query the physician. For instance, a patient with documentation of a subdural hematoma, mental status changes, and a decrease in their Glasgow coma scale may have had a brain MRI indicating mass effect and a midline shift. In this case you would probably query the physician regarding possible brain compression.