Q: I am working on a denial of 348.39 (toxic/metabolic encephalopathy). The auditor asserts that mini mental status exams are required for this diagnosis. Is there documentation of that requirement anywhere? Do all payers ask for that?
A: Glenn Krauss: A mental function test is not necessary if the progress of the encephalopathy is described by the physician and nursing staff. Herein lies the challenge of the clinical validation that payers capitalize on.
CDI specialists are taught to query for “encephalopathy” and “sepsis” in any clinical scenario where the patient exhibits a change in mental status. Typically the CDI specialist queries the physician for further specificity on these diagnoses, the physician responds to the query and documents the diagnosis, and the diagnosis appears once or twice in the progress notes without any documented clinical thoughts as to the contributing factors, relationship to other disease progressions, or abnormal clinical values. All we have is the word “encephalopathy” as a conclusory statement with little or no discussion of the clinical facts of the case.
In today’s cutthroat environment between providers and payers, conclusory statements without any relationship to the case are not sufficient for accurate depiction of clinical acuity and assignment of ICD-9 (soon to be ICD-10) codes.
Consider the diagnosis of acute renal failure: It was so over assigned and possibly over-documented through the CDI query process that CMS downgraded the diagnosis to a CC. This will likely be the case with encephalopathy. CDI specialists should encourage physicians to expand on documentation of their thought processes and clinical judgment, with brief synopsis of clinical rationale and patient’s response to therapy, whether it be improvement in the underlying diagnostic precipitation of the encephalopathy or correction of a drug-drug interaction, and the subsequent improvement or lack thereof of the encephalopathy.
I sometimes wonder if CDI programs are an asset or liability to an organization, contributing to increased denials and additional work of appeals with the capture of CCs and MCCs that are subsequently refuted on the basis of clinical validation by the Recovery Auditors and insurance companies.
A: Lee Fanning, MD: The diagnosis is made when patient comes into the hospital and is related to dysfunction of the brain due to physiological issues (i.e. metabolic) causing the dysfunction. A routine description of how the patient is improving or not, compared to how they were on admission, is enough to determine the patient’s progress or lack thereof. It sounds like those making this denial overanalyzed the need for level of mental status from the physician, when it is often found in the nurse’s notes and usually ordered in time increments consistent with the severity of the acute encephalopathy. I think, with a thorough review of nurses notes, you will find that both neuro function and mental status review can be found to fight the denial. A specific mental function test is not necessary if the progress of the encephalopathy is described by the physician and nursing staff. I would strongly resist this type of clinical pigeon holing.
I don’t think CMS downgrading certain DRG diagnoses, like encephalopathy, because it’s over used by physicians, matters in the long run. Medicare will continue to cut and slash reimbursement in both the coding world and the medical necessity world through the Recovery Auditors and downgraded DRG reimbursement payments. Reducing physician and hospital payments is appealing to both political parties as it decreases the need to ask Congress for more money for our burgeoning cost of health care. In my opinion, the Recovery Auditors are here to stay.
Editor’s Note: Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, Executive Director of the Foundation for Physician Documentation Integrity; and W. Lee Fanning, MD, FACP, Medical Director of Utilization at Carolina’s Healthcare System, responded to this question. Contact Krauss at firstname.lastname@example.org. Contact Fanning at email@example.com.
Q: Do you have any advice or guidance on how to conduct chart reviews for beginners in CDI? I am looking for specific strategies and approaches that might help our program, such as viewing labs first, or looking at emergency room (ER) notes, or history and physical notes (H&P)?
A: New CDI specialists travel a steep learning curve. There are so many components to master like regulatory guidelines, reimbursement, and even clinical, pathophysiology, and pharmacology. Nurses often specialize in a certain clinical area. Then, suddenly, as a new CDI staff member, you might need to review a record of a patient in entirely different specialty and find missing or undocumented diagnoses.
The record review is the central component of what CDI specialists do. I can only tell you what has worked for me, but my advice is, once you find what works for you, stick to the plan. I find that when I jump around a record in a disorganized fashion, I tend to miss important pieces of the puzzle.
The first thing I look at is the physician order for admission. I want to see where the patient was admitted from, for example, direct admission, same day surgery, ER, observation, clinic, etc. I want to review this to ensure I have an adequate order, specifying inpatient admission and why it was necessary, stated by the physician.
From there, I go to the first piece of documentation, which is usually the ER physician record. This record gives me the backstory, the initial labs and diagnostics, and a description of the patient when they were first seen. If there seems to be conflicting data, or if I have a specific concern, I will review the emergency department nursing notes or emergency medical technician reports at that time.
Then, I move to the physician’s H&P. I want see if the two match, or if there is a conflict. I check to make sure the physician documented the clinical indicators which support the diagnoses.
After the H&P, I usually move to additional labs and diagnostic study results, mainly because I want to ensure I have support (clinical indicators for the diagnoses, and note any values or interpretations of concern to support any missing diagnoses, present on admission status, etc. After the labs, I review all the progress notes, consults, etc.
Then, I return to the orders. I check for orders for medications without an identified indication. I look for treatments or tests that might indicate a missing diagnosis. I see if the orders support identified diagnoses.
After the orders, I go to the documentation of ancillary staff, such as nursing admission assessments, nursing notes, physical therapy, occupational therapy, speech, dietician notes, case management notes, etc. The notes from these professionals often assist in understanding the patient’s baseline conditions, and often help us to identify any secondary diagnoses not mentioned in the provider’s initial assessment.
Review the medication history and compare it with what the physician ordered for the hospital stay. What is new? What is not ordered? What has been changed? Any changed dosage or route may indicate a chronic condition that is now acute.
If your patient went to the operating room, review both the anesthesia record and the operation notes. The anesthesia pre-operation assessment may indicate secondary diagnoses not mentioned by the surgeon. The anesthesia intraoperative record will indicate medications and treatments administered in the operating room. Often, this is my first indication of possible complications. Then I review the operation notes, making sure the planned procedure matches the actual procedure performed, and, if not, I need to find out why. I also check if the pre-operative diagnosis matches the post-operative diagnosis and, if not, again I need to find out why.
At this point you should have a pretty good understanding of the patient’s condition and plan. I note any discrepancies, conflicting documentation, and possible missing diagnoses or present on admission issues along the way. Then, I can start the process of drafting queries as needed.
Now, for a repeat review, I follow my notes. If my notes are organized, I can identify what I have looked at and what is pending. When I return to the record, I can quickly identify where I left off and start with pending labs, new progress notes, etc.
As you start this process, do not get discouraged if you miss pieces. There are a number of ways to improve your skills. One great method when training, if you have a mentor or preceptor with you, is for both of you to review the record separately, and then compare answers. Look at how your co-workers “attack” the record review, and learn from their best practices.
Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her firstname.lastname@example.org. For information regarding CDI Boot Camps visitwww.hcprobootcamps.com/courses/10040/overview. The next Boot Camp will be held April 27–30, 2015, in Washington, D.C.
Q: Is the statement “please document in a progress note to capture the severity of illness (SOI), risk of mortality (ROM) and care needed for this patient” appropriate to use in a query? In general, is it appropriate to mention SOI/ROM and support level of care and profiling when querying physicians?
A: Many mature CDI departments know that providers respond better to discussions regarding the SOI/ROM than they do regarding reimbursement (i.e., discussions of dollars). Most providers feel they treat the “sickest of the sickest” and pointing out how their documentation affects quality measures and reporting illustrates the direct benefit of CDI efforts for them and their patients.
However, it is important to have discussions with providers explaining the relationship between documentation, reimbursement, healthcare quality, profiling, etc. CDI staff should share information regarding the importance of SOI/ ROM during formal training sessions with the medical staff and as the opportunity arises during impromptu interactions with individual providers on the hospital floors.
I subscribe to the concept of keeping the query as concise and simple as possible. Therefore, I would not include this type of language you provided as part of the query process itself.
As an additional note of caution, since the MS-DRG and APR-DRG reimbursement systems are based on the “severity” of the patient’s condition—the more “severe” the patient’s condition, presumably, the higher the reimbursement—providers may associate the discussion with a secret code of sorts. “When I say SOI/ROM, you know I’m really addressing reimbursement.”
The 2013 query practice brief, Guidelines for Achieving a Compliant Query Practice Brief states:
“A query should include the clinical indicators…and should not indicate the impact on reimbursement.”
Consider circling back to a provider if he or she fails to respond to a query and explain why the query was placed and how a change in documentation could have positively affected reimbursement, healthcare quality, profiling, etc., reinforcing the initial education provided. Physicians often respond to concrete examples. When such is associated with their own documentation, even better. Timing such discussions and including additional illustrations of both effective and deficient documentation to prove your point helps take the emphasis off a specific situation which may be deemed leading and places it within the realm of overall program goals and general documentation improvement.
Also, I always encourage CDI specialists to trust your gut. If it feels a little murky to you, then don’t do it. Nothing is worth compromising your integrity and ethics.
Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, Associate Director for Education at ACDIS and CDI Education Director at HCPro in Danvers, Mass responded to this question.
Q: In my facility, we are supposed to send an e-mail to our physician advisor (PA) and to administration if a query is not answered within a week. However, this policy doesn’t work well because administration does not do anything with that information, and the PA doesn’t have time to review unanswered queries. Do you have any suggestions concerning when to let a query go unanswered?
A: We do suggest every CDI program have well-developed query policies. These should be consistent with those policies followed by the coding department. Look at how unanswered queries are addressed on the retrospective side.
Your query policies should include clear guidance on what instances queries are to be asked, where they are placed within the record, and who is responsible for follow-through. You should also have guidance on how queries are to be prioritized.
Query policies should also include an escalation policy that describes how to handle situations in which an answer is not received, an inappropriate answer or comment is provided, etc. The escalation policy should address when the issue is brought to the physician advisor, your department director, or administration with defined actions as to the responsibilities at each level. The policies should reflect a method of response that can realistically occur for your organization.
In my experience, if a query was unanswered, the CDI specialist and inpatient coder would discuss the need for follow up. If it was determined that the answer would provide little impact, we would close it, leaving the query unanswered. But if we concluded an answer was required, the CDI specialist would address with the provider. There was a process of escalation in those instances when no response was received.
Ultimately, your policies should indicate what instances a query can go unanswered, and when it should be followed through. There may be instances when a query does not impact the reimbursement or quality measures and can be left unanswered. These are conversations that must be discussed within your organization.
Few organizations can boast a query response rate of 100%, but there are some things you can do to boost response rates. Take a look at your query templates or perform a query audit. There should always be choices that allow the physician to offer his or her own interpretation, or to state that there is no significance or the answer is unknown. Often, physicians do not answer queries because they either do not like the choices offered or they are unsure exactly what is being asked.
It might be helpful to monitor physician query response rate based on the CDI specialist responsible for the account. You may find a specific CDI specialist is having difficulty writing effective queries or lacks assertiveness in follow-up on unanswered queries. Most programs have a set time limit or goal for queries to be answered that is tied to individual CDI productivity or effectiveness in the role. For example, an expectation that 80% of all queries asked will be answered within 48 hours.
Administrative support is invaluable in encouraging physician involvement in your program. Many organizations track physician response rates to queries in their physician profiling, or “quality report card” efforts. Instead of forwarding administration every unanswered query, set an acceptable response rate. When a physician falls below the suggested benchmark, the matter should be addressed by a department director, PA, or senior administration.
I also like to give positive reinforcement where it is due. Recognize those physicians who are working with you and are demonstrating a high response rate. It creates a sense of competition and, often, we catch more flies with honey.
Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at email@example.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview. The next Boot Camp will be held April 27–30, 2015, in Washington, D.C.
Q: A patient came to the emergency department with shortness of breath. The admitting diagnosis was possible acute coronary syndrome (ACS) due to shortness of breath (SOB) and elevated troponin levels. The ACS was ruled out. Elevated troponin levels were assumed to be due to chronic renal failure (CRF), and no reason was given for SOB. Before discharge, the patient was noted with an elevated temperature and found to have a urinary tract infection (UTI). All treatment was directed at the UTI, and the doctor noted the discharge diagnosis as the UTI. What would be the principal diagnosis in this case?
A: Without knowing all the specifics, and reading how it was presented, I would say the UTI could not be taken as the principal diagnosis. For the UTI to be the principal diagnosis, we would need to query for two pieces of information.
- The first issue would be whether or not the UTI was present on admission. From this description, it does not was appear to have been not present on admission, but the symptoms appeared before discharge.
- The second concern would be to determine whether the UTI was somehow linked to the patient’s presenting symptoms. A UTI and SOB is a difficult connection to make.
If we eliminate the UTI as a choice, even if the majority of treatment was directed towards to the UTI, we have little to work with. I would query for the probable or likely cause of the SOB. If the provider answers with a definitive diagnosis then this would be your principal diagnosis. If not, the symptom of SOB would be your principal diagnosis.
The bigger concern with this patient might be that the wrong status was assigned. This patient most likely should have remained outpatient and placed in observation status until a more definitive diagnosis could be found warranting an inpatient admission.
Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her firstname.lastname@example.org. For information regarding CDI Boot Camps visitwww.hcprobootcamps.com/courses/10040/overview.
Q: Where can I go to find out if the word “excisional” must be written by the doctor to code an excisional debridement?
A: Many professional coders will say that the physician must include the word excisional in order to assign a code for excisional debridement.. I always taught students to use this word as well. So let’s start our investigation as to where this rule came from by taking a look at the Official Guidelines of Coding and Reporting. If there isn’t any direction here (and in this case, there isn’t) we’d turn to the instructions in the alphabetic and tabular index of the code set. Actually, we should really start with the index, as these guidelines need to be applied first when assigning a code..
At code 86.22, excisional debridement of a wound, infection or burn, states “for removal by excision of: devitalized tissue, necrosis, and slough.” No other terms or synonyms are used to describe how the tissue was removed, except for excision. So physicians need to use that word specifically.
Now if you are debating this with a surgeon, he or she will have little desire to understand the inner workings of the code book. However, a number of AHA Coding Clinics offer guidance.
Specifically, AHA Coding Clinic for ICD-9-CM, First Quarter, 2013, states that the requirements in the index were intended to “encourage improved documentation…as to the type of debridement performed.” It includes an example of a patient with a traumatic open wound, stating that clinically an excisional debridement may not be clinically performed and that in many cases a nonexcisional debridement may be needed to clear the problematic area.
“Clear and concise documentation is needed,” Coding Clinic states. “It is critical that hospitals work with their providers to ensure that the documentation used to support excisional debridement clearly describes the procedure.”
Editor’s Note: The ACDIS Forms & Tools Library also includes sample query forms. For more information regarding this topic see these additional articles:
- Prevent RAC denials: Improve excisional debridement documentation
- Context matters with excisional debridement
- Q&A: Coding for surgical debridement of devitalized tissue with scalpel
- Follow these nine tips to capture inpatient wound care correctly
- Tip: Anatomy to know when capturing debridement documentation
© Copyright 1984-2014, American Hospital Association (“AHA”), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.
CDI Boot Camp Instructor Laurie Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, answered this question. Contact her at email@example.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview.