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Q&A: Acute pulmonary insufficiency

Have CDI questions?

Have CDI questions?

Q: What should we do about the documentation of “acute pulmonary insufficiency?” What indicators are you using for this in comparison to querying for acute respiratory failure? Acute pulmonary insufficiency is an MCC following surgery but it is also a potential patient safety indicator (PSI) if it’s failure. 

A: Our process is to review the chart and see if it meets clinical evidence for additional specificity such as acute respiratory failure. If it does not, does it meet clinical evidence for acute respiratory distress (now that there is a new code for that condition)? If it does not, then our CDI teams would not query. If it does meet the criteria, we would add all the relevant information from the record on the query and ask the physician if, in his or her medical opinion, the documented acute pulmonary insufficiency could be further specified. [more]

Guest Post, Part 2: Where do we stand with clinical validation?

clinical validation poll(1)

According to an ACDIS poll, 70% conduct clinical validation reviews.

By Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS

At the 2017 ACDIS conference in May, Nelly Leon Chisen, RHIA, director of coding and classification, the executive editor of the American Hospital Association’s (AHA) Coding Clinic provided clarification on the new Official Guidelines for Coding and Reporting, I.A.19 titled “Code Assignment and Clinical Criteria.” (Read last week’s post here.) At the meeting, Nelly explained the Guidelines intended to reaffirm long-standing advice that coding must be based on provider documentation, essentially that:

  • Only the physician, or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis, can “diagnose” the patient.
  • Clinical information published in Coding Clinic does not constitute clinical criteria for establishing a diagnosis, substitute for the provider’s clinical judgement, or eliminate the need for provider documentation regarding the clinical significance of a patient’s medical condition.


Guest Post, Part 1: Where do we stand with clinical validation?

clinical validation queries

According to a recent survey, 44.88% send 5 or more clinical validation queries monthly.

By Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS

The 2017 Official Guidelines for Coding and Reporting, effective October 1, 2016, contained a new, perplexing, and problematic section I.A.19 titled “Code Assignment and Clinical Criteria,” which states:

“The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists.  The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

This has been incorrectly interpreted by some to mean that clinical validation of documented conditions is no longer required for code assignment on claims.


Guest Post: Altered mental status remains a challenge in ICD-10-CM – part 2

James Kennedy, MD, CCS, CDIP

James Kennedy, MD, CCS, CDIP

By James Kennedy, MD, CCS, CDIP

Determine the underlying cause of the altered mental status

Remember that the various forms of altered mental states have underlying causes, which, if defined, diagnosed, and documented, accurately represent the patient’s condition for risk-adjustment purposes. Options include:

  • Neurodegenerative disorders. To the extent that it’s possible to state what the underlying degenerative brain disease is, please do so. Options include Alzheimer’s disease, Lewy-body dementia, late effects of multiple strokes, normal pressure hydrocephalus, some cases of Parkinson’s disease, and a host of others. Note: The term “multi-infarct dementia” requires additional documentation that it is the late effect of multiple strokes. Consider the word “encephalopathy” as well (see the next item) when documenting these underlying causes.


Guest Post: Altered mental status remains a challenge in ICD-10-CM – part 1

James Kennedy, MD, CCS, CDIP

James Kennedy, MD, CCS, CDIP

By James Kennedy, MD, CCS, CDIP

In ICD-10-CM, defining, diagnosing, and documenting the various forms of altered mental status and their underlying causes remains an ongoing challenge for physicians and their facilities.

Even the esteemed New England Journal of Medicine states that, “‘Altered mental status,’ a nonspecific term that is frequently used to describe alterations in alertness, cognition, or behavior, is commonly encountered in the emergency setting.” If you have a subscription or access through your medical library, review the discussion at [more]

Q&A: Missing documentation for acute kidney injury


Ask ACDIS all your CDI questions!

Q: We are currently coding a chart for an acute kidney injury which has the baseline serum creatinine and urine output missing from the chart. Is there something we can do to identify additional information before we have to query the physician?


Note from the instructor: Increase understanding of pathophysiological concepts for CDI


Laurie L. Prescott, MSN, RN, CCDS, CDIP

by Laurie L. Prescott, MSN, RN, CCDS, CDIP

CDI specialists depend on clinical indicators to support queries. Hospitals and physicians need clinical indicators to support the validity of documented diagnoses.

Clinical indicators include patient presentation, symptoms and complaints, lab and diagnostic studies, and ordered treatments such as medications, interventions, monitoring, and assessments. You can find clinical indicators in the documentation of nursing and ancillary staff. As part of our work with clinical validation, all CDI specialists and coders have to work with providers to ensure diagnoses are well supported within the record. It is not enough to obtain documentation of a diagnosis; we must ensure the record clearly supports its presence.

To concentrate on these issues, we have developed a new boot camp to help increase understanding of pathophysiological concepts. The Mastering Clinical Concepts in CDI Boot Camp is designed to assist in the process of clinical validity reviews by examining a number of diagnoses common to both CDI and audit challenges. The Boot Camp discusses diagnostic interpretations, signs and symptoms, and common treatments and covers interventions to strengthen students’ knowledge and competence in record review.

These concepts will assist CDI teams in identifying vague or missing diagnoses regarding neuro, respiratory, cardiac, gastric, liver, musculoskeletal, endocrine, and renal diseases among others and increase staff confidence in speaking to providers and working to ensure adequate documentation in the record. During class, we use real-life scenarios to drive discussions about challenging CDI reviews and help our students:

  • Increase your understanding of key pathophysiological concepts
  • Improve the quality of clinical indicators used when you query
  • Cultivate critical thinking skills for use with data involving complex clinical concepts
  • Improve your ability to distinguish evidence-based clinical indicators from other data in the record

I’m looking forward to teaching this new boot camp aimed at experienced CDI professionals looking to advance their careers with next step training. This course is also valuable for coding staff who wish to increase their clinical understanding of the records they review.

We look forward to seeing you in class!

Editor’s note: Prescott is the CDI education director for ACDIS/HCPro. She is a frequent speaker and author of The Clinical Documentation Improvement Specialist’s Complete Training Guide.

Guest Post: Ensure clinical validity to obtain physician support for query efforts

Cesar M. Limjoco, MD

Cesar M. Limjoco, MD

We often hear from providers about the seemingly endless number of queries they have to contend with. Nowadays they feel pulled in many directions. How can CDI staff help assuage the overwhelmed provider to make their engagement with the CDI program a win-win for everyone?

The most important thing in the success of a CDI program is provider buy in. In order to keep them engaged, a CDI specialist needs to appeal to their senses of clinical accuracy and data integrity. All quality measures—including morbidity/mortality, patient safety indicators, complications, etc.—are riding on the type of severity of illness captured in provider documentation. If true severity of illness is not captured, it looks like the providers are doing a poor job.

An evidence-base query/clarification can help. The CDI specialists should not be asking questions just for the sake of asking questions (high query rates with no real capture of severity of illness is counter productive). Queries have to make sense. The provider has to have a clue as to what he or she is being asked. It would be senseless to ask for the heart failure type (systolic/diastolic) without the echocardiographic findings, for example.

By ensuring that queries are clinically significant, you will keep the providers engaged. Clinical parameters/definitions are not infallible. They are like mile-markers on the pathway to a diagnosis. There are many things that will satisfy diagnostic criteria, but do not really make the diagnosis. For example, one of the things that differentiates massive pulmonary embolism from sub-massive and low-risk PEs is the presence of hypotension. But if the hypotension is caused by a different source (e.g., hypovolemia, medication, etc.), then it does not meet the requirements for a diagnosis of massive pulmonary embolism.

The same goes for the two out four SIRS/Sepsis criteria. patients with many types of infections may satisfy two of the four criteria (e.g., fever and leukocytosis) but are not septic. The provider needs to determine if the patient’s signs and symptoms are beyond what is expected in a localized infection. The presence of systemic manifestation that cannot be explained by the localized infection (or any other etiology) but now truly represents a toxic immune system response is what makes the diagnosis of sepsis. It is common to find elderly nursing home patients referred to the ED for altered mental state, hypotension, and found to have delirium due to a urinary track infection. That patient isn’t really septic. If rehydration corrects the mental status and the hypotension then what the patient truly had was hypovolemia (dehydration) with some UTI and nothing more.

If you approach the provider with waht is documented in the chart and ask what they actually mean, you will get a better understanding of what is truly going on in the case. Keep an open mind to learning, and ask your questions in a way that provider has some idea of how to answer it. In some cases, that’s easy and clear. In others, the potential answers are not intuitive at all and some guidance is needed. The providers may not know or fully understand what’s happening at the outset. But the real story will come out, and that’s what CDI is all about.

Editor’s Note: Limjoco has more than 25 years of experience as a consultant with expertise in the capture of severity of illness in clinical documentation.  Since 2005, he has served as Vice President of Clinical Services of DCBA, Inc., performing coding and clinical documentation assessments and implementing, maintaining, and revamping CDI programs. This article originally published in the DCBA, Inc. enewsletter CDI Talk.

TBT: Take another look at lung cancer cases to capture specificity

Look to clarify lung cancer concerns

Look to clarify lung cancer concerns

Editor’s Note: In social media memes Throw-back Thursday generally means sharing an old high school photo of you, something you most likely wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We’ve picked up the theme going back into our CDI archives to highlight some salient CDI tid-bit (rather than our fashion sense or lack there-of). Today, we’ve chosen to the CDI Journal article Take a closer look when reviewing lung cancer chartswhich originally published in the April 2011 edition.

by Helen Walker, MD

Lung cancer is the principal diagnosis in about 150,000 hospital admissions per year and a secondary diagnosis for roughly 386,000 admissions. Patients admitted with lung cancer either as a primary or secondary diagnosis require a longer length of stay than an average admission (source: Healthcare Cost and Utilization Project website, CDI specialists should know what to look for when reviewing cancer admissions in order to capture the true severity of these patients’ illnesses.

The ICD-9 codes related to lung cancer are assigned based on the following factors:

  • Documentation of a lung malignancy
  • Type of cancer
  • What part of the lung is involved
  • Whether the cancer is primary or secondary

Often patients are discharged with the diagnosis of “possible” or “probable” cancer when the pathology report is still pending. Although “probable,”  “suspected,” “likely,” “possible,” and “still to be ruled out” diagnoses can still be coded as a malignancy, it is best to have the attending physician provide documentation. The department in charge of the post-discharge query process (typically CDI or HIM) should query the physician if the pathology report returns after discharge.

The majority of lung cancers are non-small-cell carcinomas. These include the following:

  • Adenocarcinoma
  • Squamous cell carcinoma
  • Large-cell carcinomas
  • Non-small-cell/non-large-cell carcinomas

Thirteen percent of all lung cancers are small-cell carcinomas. Look for documentation to establish whether the lung cancer is primary or secondary. Many cancers metastasize to the lungs, including breast cancer,  gastrointestinal tumors, kidney cancer, melanoma, sarcomas, lymphomas and leukemias, germ cell tumors, and ovarian cancer. So if there is a question whether a tumor is metastatic to the lung, or from the lung, query the physician.

Note: Walker is vice president of clinical quality at FairCode Associates, LLC, a healthcare consulting firm specializing in DRG and coding audits. Contact her at

Q&A: Determining standard clinical criteria for common diagnoses

Go ahead, ask us!

Go ahead, ask us!

Q: I understand that most CDI departments develop a standardized list of clinical indicators/criteria to support query efforts. Is this something we need to develop or is it available in the encoder process? If we need to develop this, how do we go about that?

A: While the AHA’s Coding Clinic for ICD-9-CM (ICD-10-CM/PCS) often lists clinical indicators for specific diagnoses, the publication should not be used as a stand-in for the provider’s own clinical judgment, as reiterated in Coding Clinic, First Quarter, 2014, p. 11.

CDI programs should work with the physician team to develop a standardized list of clinical indicators for the team to use in query creation, CDI and physician training, and record review. Such mutually developed criteria is particularly helpful for highly vulnerable or often miss-documented conditions such as levels of malnutrition severity, acute and chronic respiratory failure, acute kidney injury, encephalopathy, etc.

Research nationally established guidelines for these common, core conditions (e.g., ASPEN criteria for malnutrition, or RIFLE or NKIDO criteria for renal failure), then work with the specialty most closely related to that diagnosis (e.g., pulmonologists for acute respiratory failure). This criteria could then be consistently used by CDI and coding staff to initiate a query to support the diagnosis.