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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.


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.


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.

Book Excerpt: Documentation pocket cards as physician training tool

Many programs have developed their own home-grown documentation pocket cards, or tip sheets, based on the clinical topics most apropos to their specific facility. Some handouts are a simple piece of paper developed by the CDI team, whereas others are laminated, elaborately formatted cards from consulting companies distributed as part of the initial implementation program.

In general, a pocket guide explains that physicians must document underlying conditions, not simply the signs and symptoms of the concerns, and link the disease to the underlying cause whenever possible. It also directs physicians to document “suspected,” “likely,” or “probable” in the absence of a definitive diagnosis.

Many facilities include prompts for more specific diagnoses such as systemic inflammatory response syndrome (SIRS) and multiple organ failure and an alphabetical list of important conditions frequently forgotten by physicians, such as:

  • Acute exacerbation of chronic obstructive pulmonary disease (COPD)/asthma
  • Malnutrition
  • Metabolic/respiratory acidosis
  • Metabolic/respiratory alkalosis
  • Sepsis/severe sepsis/septic shock
  • Systolic/diastolic heart failure
  • Pneumonia

If generating a tip sheet for your facility, list common nonspecific terms physicians frequently use to describe patient care and compare them to similar ICD-9-CM terms that, when coded, reflect a greater severity of illness (SOI) for the patient. For example, “cystitis” may also be “urosepsis”/ “urinary tract infection (UTI),” or it may be “sepsis due to UTI.” Each term progressively increases the patient’s SOI.(6)

Some tip sheets also include Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) quality measures, history and physical (H&P) documentation, discharge summary consistency, POA, and hospital-acquired conditions (HAC). Employing such cards during both initial and subsequent training programs:

  • Ensures everyone speaks the same language
  • Promotes facility-wide team building
  • Provides additional avenue of education regarding CMS/RAC updates

Editor’s note: This article was taken from The Clinical Documentation Improvement Specialist’s Handbook, Second Edition written by Marion Kruse, MBA, RN, and Heather Taillon, RHIA.

Pamela P. Bensen, MD, MS, FACEP, CEO of Medical Education Programs, Inc. in Buffalo Junction, VA, created a laminated pocket guide for physicians  available in packs of 25.

When asked about anemia

I challenge you to find one textbook of medicine, physiology, or pathology that refers to a category of hematologic abnormality as “acute blood loss anemia.”

Help coders ask physicians the right questions

But coders are very familiar with that term. They may ask a physician whether a patient has acute blood loss anemia. Or they may ask, “What kind of anemia is this?” And physicians essentially have no chance of ever guessing that they are after “acute blood loss anemia” or even “chronic blood loss anemia.”

What coders really want to know is the cause of the patient’s anemia. Was it anemia due to acute blood loss from a ruptured esophageal varix or from a fractured femur? Was it anemia due to chronic blood loss from hematuria from a patient’s multiple bladder polyps or from menometrorrhagia? Was it anemia due to a chronic infection such as chronic osteomyelitis or chronic hepatitis C? Was it anemia due to the patient’s CKD 4?

That’s why the CDI specialists need know how to take that basic coder impulse and help to ask the right question, and obtain the most accurate documentation for the care the physician provided. After all, it’s the end result that counts—and makes everyone happy.

Editor’s note: This article first appeared in the September 2010 edition of Medical Records Briefing.

Book excerpt: Measuring process and outcomes

The long-term viability of a CDI program is incumbent upon being able to show hospital and medical leadership the scope of work performed and how it influences the hospital. The best way to accomplish this is through the creation of a CDI Dashboard that tracks outcomes and operational measures.

Operational measures can help balance the CDI specialists’ workload and pinpoint areas where CDI staff members need additional education. These combined measures will help to identify areas needing improvement so that action plans can be developed. At a minimum, the Dashboard should include the following metrics:

Outcome measures by payer class:

  • Medical CMI
  • Surgical CMI with and without tracheostomies
  • Medical complication and comorbidity (CC) capture rate

    Use a Dashboard to track your program progress.

  • Medical major complication and comorbidity (MCC) capture rate
  • Surgical CC capture rate
  • Surgical MCC capture rate
  • Measurements related to the “key pairings” (now some are triads) as identified by the Office of Inspector General and noted in the PEPPER Report
  • Financial impact based on changes in CMI from baseline measurements

Operational measures:

  • Number and percentage of cases reviewed by CDI specialist
  • Percentage of cases with queries
  • Physician response rate broken down by agree, disagree, and unanswered
  • Percentage of cases where CDI specialist and coder final DRG did not match
  • Variances in results with their related reasons; for example, if the CMI decreases due to the vacation schedule of an internist

Further breakdown is recommended and can be customized to each facility. CMI and CC/MCC capture rate can be compiled by each specialty/medical department, physician, and coder. CDI leadership should produce and distribute the Dashboard to various stakeholders on a monthly basis. The CDI task force should be responsible for analyzing and identifying troublesome patterns and formulating action plans. The CDI steering committee should be responsible for communicating results to the hospital board of directors. The physician advisor should communicate the results to the medical executive committee. Also, hospitals should explore purchasing national benchmarks if their current Dashboard does not include them.

The Association for Clinical Documentation Specialists (ACDIS) is one potential source of benchmark data related to CDI program operational measures. Data for outcome measures include MedPar data and the various companies that provide data mining services.

Editor’s Note: This article was originally published in The Physician Queries Handbook: Guide to Compliant and Effective Communication.