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Take 10 steps to refresh your documentation review process

Ensure your CDI programs examines patient records "door-to-door."

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.


Reflections on physician leadership and engagement with CDI programs

Over the past several years there have been a number of conversations that touch on physician leadership involvement with CDI. Programs can and do achieve success, but so much more is achieved when there is a proactive and supportive medical voice.

Physician leadership can come from a number of sources and in a variety of forms. Some CDI programs (a few anyway) report directly or indirectly to a physician executive (medical staff functions, chief medical officer [CMO], etc.) and other programs report to the quality department where a physician executive is frequently directly involved. In these circumstances, I hope the physician executive maintains some amount of time dedicated for CDI efforts.

Some organizations are fortunate enough to have physician leadership within the broader organization that is (or have been convinced to be) very supportive to CDI efforts. From what I’ve heard, these frequently include CMOs and chiefs of staff and/or service lines within a given facility. Finally, some physicians, such as a medical director, physician champion, advisor, or liaison, devote a portion of their time to work directly with CDI. (Read more about the expanding roles and responsibilities of CDI physician advisors in the January 2012 edition of the CDI Journal.)

Furthermore, even with supportive medical staff leadership, how that support translates into action varies. Some facilities provide physicians time to offer educational sessions to their CDI and coding teams. Others provide CDI education sessions to entire physician groups by service line.

Most CDI programs earn physician leadership and support through the tireless efforts of the CDI staff and program leaders. Only occasionally have I seen this support present from the very beginning.

Some Perspectives

I’d like to look at the “state of affairs” in regards to physician leadership.  One ACDIS weekly online poll (2008) addressed the simple question of whether respondents had a “physician champion” and if that champion was effective. That poll was rather surprising; only 46% indicated they had a physician champion, and half of the respondents with a physician champion actually rated him/her as ineffective. So, according to that poll, only 23% of programs have an effective physician advisor.

ACDIS repeated the  poll (with slightly different wording) in April 2011 and though the results showed some improvement, they were still discouraging. In 2011, 31% described having a very beneficial physician champion, 22% described their physician champion as “’minimally effective”, 24% felt the position was not affordable, and 16% indicated that their program could not find a good candidate. Even more surprisingly to me, 7% said they simply did not see the need for the roll.

Additional polls from 2008 which echo the theme of limited physician support for CDI programs include:

Other recent poll responses illustrate different aspects of physician involvement in CDI , but I thought these painted an interesting picture.

Don’t forget the most recent study, published in the January CDI Journal, in which 73% (178 individuals) indicated that their physician advisor spends five hours or less dedicated to CDI efforts, and 54% described their advisor as either moderately effective or ineffective.


I think it is  important to have data to effectively measure any focus area of interest. I believe a couple of key metric data pieces provide insight to the level of success with physician engagement. In any analysis, I would include items such as:

  • Physician response rates
  • Severity of illness (SOI)/risk of mortality (ROM) data
  • Trends in volume of queries and more specifically the focus of queries (Do CDI staff ask the same queries repeatedly?)

I specifically would not include physician agreement rate except in a broader sense in looking for individual outlier physicians, to find those who either agree to whatever the CDI specialist asks or those who never agree with the premise of a CDI specialist’s query.

As always, I’d love to hear what elements other CDI programs use to statistically validate their physicians’ involvement with and support of their CDI programs.


Quite a bit of material is available between the ACDIS online polls (I have fun with those, obviously), various blog postings, journal articles, and conference presentations that offer useful information regarding physician engagement. Several provide inspiring examples of successes. Various items from other organizations are in the public domain.

If you are interested, shoot me an e-mail or leave a comment here and I can develop a partial list of links.

Wrap -up

I am sure most agree that fostering physician engagement in CDI efforts is one of the key challenges of every CDI program.

I certainly don’t have many great answers to this question, and I’d like to hear more thoughts, experiences, and success stories. I know some great examples would be wonderful Journal articles or blog posts.

I will toss in a final thought. Organizational cultural change typically takes five years. Certainly obtaining physician interest in documentation and coded data represents a significant cultural change.

Sometimes I wonder if just need to practice a little more persistence and a lot more patience.

Cardiomyopathy: A Valentine’s Day documentation reminder

Happy Valentine's Day from ACDIS

Editor’s Note: Have a little extra thrum in your heart due to the trappings of the day? We did. So we’ve picked up this piece written by ACDIS Advisory Board members Robert S. Gold, MD, originally published in the December 2011 edition of our sister publication Briefings on Coding Compliance Strategies.

Cardiomyopathy (CMP), a disease that affects the heart muscle, is frequently misreported. When cardiologists document the term “CMP,” it usually denotes their awareness that the patient has a sick heart. They may evaluate the heart as being dilated and as having a low ejection fraction. However, they don’t always evaluate pathophysiology. Without this evaluation, documentation of CMP can be deceiving. When coders see this documentation, they report ICD-9-CM code 425.4 for the CMP even when the patient may have something else.

A quick Google search yields a variety of causes of cardiomyopathy. There are specific ICD-9-CM codes in the 425 code series for each type of cardiomyopathy. For example:

  • Codes 425.11 and 425.18 denote idiopathic hypertrophic cardiomyopathy with or without obstruction, respectively.
  • Code 425.5 denotes alcoholic cardiomyopathy.
  • Code 425.7 denotes nutritional cardiomyopathies, such as due to amyloidosis and beriberi. Some very rare cardiomyopathies are also specifically named in this section. Two examples are endocardial fibroelastosis (code 425.3) and obscure cardiomyopathy of Africa (code 425.2).
  • Code 425.8 denotes other specified cardiomyopathies in diseases classified elsewhere that can also affect the heart muscle and its function. These include Friedreich’s ataxia, progressive muscular dystrophy, sarcoidosis, and myotonia atrophica.

Other specific causes of cardiomyopathy are not included in the 425 code series.

If you look for hypertensive cardiomyopathy in the Alphabetic Index of the ICD-9-CM manual, it leads you to hypertension with cardiac involvement. This leads you to the 402–404 code series.

Hypertensive cardiomyopathy is a type of cardiomyopathy; however, it doesn’t exist in the 425 code series. Coding Clinic, Second Quarter 1993, p. 9, instructs coders to assign both the 402 (or 404) series code and code 425.8 to designate cardiomyopathy in diseases classified elsewhere.

Similarly, ischemic cardiomyopathy (code 414.8) is not listed under cardiomyopathy even though it is a cause of heart disease that can lead to dysfunction. No advice exists for the addition of code 425.8 even though it is among the most frequent causes of cardiomyopathy in the United States. This represents an error in the coding system. ICD-9-CM code 414.8 denotes ischemic heart disease just as codes 403 and 404 denote hypertensive heart disease. They each require code 425.8 to capture the complete description of the condition.

Several Coding Clinic references cite code 425.4 (other primary cardiomyopathies) for cardiomyopathy. These references state that coders should report this code for cardiomyopathy that includes such terms as “congestive,” “constrictive,” “familial,” “idiopathic,” “restrictive,” or “obstructive.” However, these references are incorrect. Code 425.4 should be used only for primary cardiomyopathies not otherwise specified or when physicians document one of the aforementioned nonessential modifiers.

When a patient has cardiomyopathy that is secondary to another condition—and the cause is unknown—coders should report code 425.9 (secondary cardiomyopathy, unspecified). When the cause is known, they should report code 425.8. These codes (i.e., 425.8 and 425.9) should be used when documentation includes any one of the nonessential modifiers listed under code 425.4 and when the cardiomyopathy is due to another condition.

The term “idiopathic” means that the physician cannot determine the cause of the cardiomyopathy despite extensive workup. If the physician can determine the cause, then by definition it’s secondary cardiomyopathy.
Ischemic heart disease is a disease classified elsewhere. Similarly, hypertension is a disease classified elsewhere. Therefore, code 425.8 should be added to 414.8 (other specified forms of chronic ischemic heart disease) for ischemic cardiomyopathy.

‘As God as my witness’ there’s a query opportunity here

Can you begin to imagine how complex a piece of great literature would be in we had to include complete documentation

Chasing documentation down like Rhett Butler after Scarlet O'Hara?

of each medical incident? Or have to stop every time we have to develop physician queries?

Let’s take a look at the classic tale Gone with the Wind and see whether we can identify some areas where author Margaret Mitchell might have given us more information.

  • Scarlett O’Hara’s first husband Charles Hamilton dies of pneumonia. Viral? Bacterial? What was the treatment plan?
  • Countless soldiers are wounded and dying in makeshift hospitals. Are there coding concerns about where the injuries occurred, specifically with regard to which state the patient resides in (as the bills may go to different fiscal intermediaries)? What about POA or the possibility of readmission?
  • Scarlett learns her mother is ill but because of the war, Scarlett can’t get home to see her mother. Might Scarlett be experiencing stress and anxiety?
  • Melanie Wilkes gives birth to a baby boy, Beau. No physician is present for the delivery. Can we assume a physician saw mother and child for post-delivery examination?
  • Scarlett finds that her father Gerald has lost his mind. Is there a diagnosis of dementia or Alzheimer’s? Is it post traumatic stress disorder or due to an injury suffered during the war?
  • Gerald dies of injuries from a fall off a horse. Do we need to indicate where the event took place?
  • Ashley Wilkes is shot in the retaliation attack. Where was the wound? What procedures were performed?
  • Frank is killed in that same attack. Poor Frank. He really thought Scarlett loved him. Poor Suellen who never stopped carrying a torch for him. She was likely given a sedative and put to bed. Injection? Infusion? Shot of brandy?
  • Scarlet marries Rhett Butler and has his baby. Are there any complications noted?
  • Scarlett, pregnant again, falls down a flight of stairs and miscarries. What is the trimester? Does she suffer injuries in addition to the lost pregnancy? What drugs are administered for her injuries? Is there a plan for physician follow up? Are any specialists called in for consultation? Did she fall or was she pushed?
  • Their daughter, Bonnie Blue, falls from her horse and dies of her injuries. What is the actual cause of death and how should her other injuries (if there were any) be noted in the record?
  • Melanie is ill, suffers a fall, and never recovers. She dies. Did she fall due to the illness or injuries from the fall? What conditions were present on admission to the good doctor’s care?
  • Ashley has a broken heart. How should this be documented for appropriate coding?
  • Rhett walks out on Scarlett. She weeps and then pulls herself together and declares that tomorrow is another day. Does anything indicate that Scarlett may be suffering from delusions? The vapors?

What do you think? Do you have any other suggestions for movies or literature that we could probe for clinical documentation opportunities?

Book Excerpt: Clearly establish your program query processes

According to AHIMA, the query process has become a common communication and educational method to advocate proper documentation practices to ensure data accuracy and integrity.  Queries may be made for the following situations:

  • Clinical indicators of a diagnosis but no documentation of the condition

    The 2012 CDI Pocket Guide.

  • Clinical evidence for a higher degree of specificity or severity
  • A cause-and-effect relationship between two conditions or organism
  • An underlying cause when admitted with symptoms
  • Only the treatment is documented (without a diagnosis documented)
  • Present on admission (POA) indicator status

Definition of a Query:

A question posed to a provider to obtain additional, clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes in the patient’s health record.

Whom to Query?

Any physician or other qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis, including

(Attending Physician, Consultants, Specialists, Emergency Physician, Anesthesiologist, CRNA, Intern, Resident, Fellow, Physicians Assistant, Podiatrist  , Nurse Practitioner). When there is conflicting information, the attending physician should be queried since he/she is ultimately responsible for the final diagnoses.

When to Query?

When there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure.

AHIMA states that a query may be appropriate when documentation in the record fails to meet one of the following five criteria:

  1. Legibility
  2. Completeness (abnormal results without comment)
  3. Clarity (cause of symptoms)
  4. Consistency (disagreement/conflicting info)
  5. Precision (more specific)

When Not to Query

  • Codes assigned to clinical data should be clearly and consistently supported by provider documentation.  Coding Clinic 2000 Q2 P 17:  “When documentation in the medical record is clear and consistent, coders may assign and report codes.”
  • Queries should not be used to question a provider’s clinical judgment, but rather to clarify documentation when it fails to meet the five criteria:  legibility, completeness, clarity, consistency, or precision.
  • In situations where the clinical information or clinical picture does not appear to support the documentation of a condition or procedure, hospital policies should provide guidance on a process for addressing the issue without querying the attending physician.

Editor’s Note: This post is an excerpt from the 2012 CDI Pocket Guide by Richard D. Pinson, MD, FACP, CCS, and Cynthia L. Tang, RHIA, CCS.

Book Excerpt: Build better relationships with appropriate physician queries

The Physician Queries Handbook

There are consequences for failing to understand the critical link between patient treatment and the documentation and coding for such treatment. ICD-9-CM coding based on nonspecific physician documentation has led insurers to raise patient co-payments for certain “inefficient” providers.

In the same light, coding from nonspecific physician documentation has led to negative outcomes as seen via publicly reported mortality data posted on the CMS’ Hospital Compare website or other public websites. Here, some providers have high risk-adjusted death rates for community acquired pneumonia, heart failure, myocardial infarction, or other conditions based on ICD-9-CM coded data.

Communities have witnessed their local hospitals close in part as a result of providers’ and coders’ inability to negotiate the code-based reimbursement systems that are integral to establishing medical necessity, which is required for accurately assigning diagnosis-related groups for inpatient reimbursement. As the government and the public demand for improved quality of care and transparency of data increases, the physician documentation and coder translation of the medical record becomes almost as vital as the physical care the patient receives.

Editor’s Note: The above excerpt was written by James S. Kennedy, MD, CCS, in the introduction to The Physician Queries Handbook: Guide to Compliant and Effective Communication.