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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.

presentations.

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.

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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.

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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.

A closer look at hypotension

By Robert S. Gold, MD

If a coder reviews the chart of a patient in the emergency department (ED) or intensive care unit with documented symptoms, such as fever (or low temperature), elevated white cell count (or low white cell count), altered mental status, evidence of an infection (e.g., pneumonia, pyelonephritis, a rigid abdomen with speculation of diverticulitis or perforation of another intestinal organ), and hypotension, remember the following thought process.

Take a closer look at hypotension documentation

The chart may show that the physician gave the patient a bolus of saline (250–500 cc), or Ringer’s lactate and another bolus. If the patient perks up and feels better—and the creatinine drops from 5.4 to 2.7—then the patient likely had hypotension due to severe dehydration (ICD-9 code 276.51).

The rapid change in creatinine levels show that the patient was, indeed, pretty dehydrated and is coming back toward better levels.  However, if the creatinine does not return to the patient’s baseline within 24 hours of fluid resuscitation and remains significantly elevated over the patient’s baseline for more than 24 hours, there was likely acute renal damage or acute kidney injury.  The mechanism of the damage likely depends on the presence of absence of shock (in giving the physician a clue if it represented acute renal tubular necrosis or ATN).

The patient may have had sepsis (ICD-9 codes 038.9 and 995.92) from that infectious process and metabolic encephalopathy, explaining the altered mental status (ICD-9 code 348.31) due to the sepsis with acute renal failure.

If the patient does not respond to the fluid challenge, and the physician starts the patient on pressors (ICD-9 code 00.17), such as levophed, dobutamine, or dobutrex, coders may assume the patient is probably in shock. The question is, was it hypovolemic shock (ICD-9 code 785.59) or septic shock (ICD-9 code 785.52)? The physicians should document the presence of shock and the etiology of it in this case.

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Book Excerpt: Queries in the Medical Record

Some facilities believe that making queries a part of the medical record poses undue risk for CMS contractor scrutiny, and may present some Recovery Audit Contractor (RAC) vulnerabilities (especially regarding asking so-called leading questions) and implications of upcoding. Other facilities see CDI query forms in the medical record as a means of providing transparency. These facilities believe maintenance of the query form within the patient medical record may be used to defend against RAC audits and other government investigations.

CDI program administrators should work with compliance and general council to determine what works best for their specific facilities and set clear policies and procedures for the CDI staff to follow. CDI specialists need to know their facility’s query retention policies and how these policies affect their day-to-day activities. For example, if the queries are not kept as a permanent part of the medical record, where are the queries stored and how can a specialist access them?

Whether query forms become a permanent part of the medical record varies from hospital to hospital, but they should not be used as replacement for proper documentation in the medical record.

The overriding goal of CDI continues to be clear and consistent documentation of the patient’s SOI. Physicians must document treatment for ongoing conditions daily, label conditions no longer requiring treatment as resolved, and identify emerging conditions as they occur.

A good concurrent query process results in appropriate data coded from records in a timely manner. It also allows for a positive relationship to be developed between clinicians and coding professionals. SOI, quality of care measures, and reimbursement will also be positively affected through accurate and timely reporting of ICD-9-CM codes. Accurate and timely reporting of codes allows for a reduction in denials and ensures proper reimbursement and profiling of the hospital and physicians.

Editor’s Note: This article was excerpted from The CCDS Exam Study Guide written by Fran Jurcak, RN, MSN, CCDS. For more information on composing compliant queries and the rules which govern the query process join us for the Friday, March 18, 1 p.m., eastern, audio conference “Physician Queries: Apply Industry Guidance to Improve Procedures and Data Tracking” featuring Andrew Rothschild, MD, MS, MPH, FAAP, CCDS, and Cheryl Ericson, MS, RN.

Q&A: Querying for the link between diabetes and diabetic complications

Q: I am looking for help posing queries regarding the specific link between diabetes and conditions typically considered diabetic complications. Should we always query the physician regarding the link between the presenting symptom and the diabetes?

A: A cause-and-effect relationship between diagnoses may not be assumed and coded unless documented as such by the attending physician; therefore the CDI specialist may need to query the physician to ascertain such documentation defining the connection between diagnoses.

A query form may state that fact as an introductory statement, then summarize the patient’s clinical indications according to information from his or her medical record, and prompt the physician to indicate a potential cause-and-effect relationship if clinically appropriate. Here is sample language you might adapt to your facility’s needs:

Make sure physicians link the cause-and-effect relationship between conditions.

A cause-and-effect relationship between diagnoses may not be assumed and coded unless documented as such by the attending physician. The patient presented with ___________ (“neuropathy”, “diabetes”, and “CKD” as documented in the H/P.). Please document the cause-and-effect relationship, if any, between these conditions and the patient’s diabetes using one (or more) of the following examples as clinically appropriate:

  • Diabetic foot ulcer
  • Diabetic CKD
  • Diabetic neuropathy
  • Diabetes related: foot ulcer/neuropathy/CKD neuropathy/CKD/foot ulcer due to diabetes
  • Other __________________
  • Undetermined

This is one of those main educational messages (cause and effect) that you’ll want to communicate prior to query dissemination to the medical staff. However, the more consistently you ask this type of question, the sooner providers will get used to documenting that relationship appropriately the first time.   In my opinion, repetition and consistency achieves results.

In general, you can always ask:  “Is there a cause-effect relationship between the following conditions ______________ and ________________?  If so, please document this relationship in the progress notes and discharge summary.” Then give appropriate options similar to the ones I listed above.

Some other examples where cause-effect queries are necessary include:

  • Hypertension and heart disease
  • Diabetes and any associated complications (neuro, vascular (PVD), eye, kidney, etc.)
  • Sepsis and localized infection
  • Complications of malignancies (obstruction due to, respiratory condition due to, etc.)

If you base your query policies using AHIMA guidance documents you should be in good shape, but always have any query templates approved by your compliance officer and/or legal counsel before you start using your queries.

My opinion is that there’s nothing inappropriate in telling the providers why you’re asking the question.  In this case, you’re giving them the coding rules, which they did not previously know.

Editor’s Note: Lynne Spryszak, RN, CPC-A, CDI Education Director for HCPro Inc., Danvers, MA, answered this question. Spryszak teaches the CDI Boot Camp and its online version.