All Entries Tagged With: "physician query"
Don’t let surgical complication documentation get complicated
There’s still time to sign up for Friday’s (November 20, 1 p.m. EST) audio conference: Surgical Complications: Clinical Documentation Improvement for Compliant Coding and Accurate Quality Measures with Robert S. Gold, MD, and Lena N. Wilson, RHIA, CCS.
Wilson is the HIM operations manager of the clinical documentation improvement program (CDIP) and inpatient coding at Clarian Health Partners in Indianapolis. In her current role, Wilson is responsible for the CDI program at Clarian’s three facilities in downtown Indianapolis, and the inpatient coding operations for the downtown facilities and the two suburban hospitals.
And while many in the CDI world think that Dr. Gold requires no introduction, let me nevertheless tout his expertise as founder and CEO of DCBA, Inc., in Atlanta, GA, a consulting firm that provides physician-to-physician education programs in clinical documentation improvement. He has more than 42 years of experience as a physician, medical director, and consultant.
Surgery documentation is an area rife with concern from both the physician point-of-view as well as from the CDI and coding perspective, like Dr. Gold points out in this Friday’s presentation. Too often CDI programs improve a facility’s risk adjusted mortality index but negatively impact a surgeon’s physician profile. Such outcomes make it difficult to get physician support for CDI. He outlines the following three “Golden Rules:”
- If it is a complication of surgery, it is either a complication or surgery
- If it is a manifestation of a disease unrelated to the surgery it is not a complication of the surgery
- If it is not treated it may not be codable—but it may
Dazed and confused? Or Encephalopathy?
Altered mental status, dementia, or encephalopathy: What’s really going on with your elderly patient that presents with confusion?
The typical scenario is the elderly patient with some minor dementia, who has been living fairly independently, who is described as being more confused than usual. A work up does not indicate any acute neurological conditions but the patient is admitted with altered mental status. Further work up often reveals an underlying infection or metabolic condition. After treatment of the underlying concern, the patient’s mental status returns to baseline and the patient is discharged back to their usual living arrangements.
Don't let dementia documentation confuse you.
The resources consumed in treating this type of patient often include a head CT, neurological consult, neurological checks, EEG, sometimes even a bed in the intensive care unit. But if the physician only documents altered mental status or dementia and not a type of encephalopathy, the true severity of illness of the patient may not be accurately reflected.
So what is encephalopathy?
As defined by the National Institute of Neurological Disorders and Strokes, National Institutes of Health, encephalopathy is a term for any diffuse disease of the brain that alters brain function or structure. Encephalopathy may be caused by an infectious agent, metabolic dysfunction, brain tumor or increased pressure in the skull, prolonged exposure to toxic elements (including solvents, drugs, radiation) chronic progressive trauma, poor nutrition, or any reason for lack of oxygen or blood flow to the brain.
The hallmark of encephalopathy is an altered mental state. Depending on the type and severity of encephalopathy, common neurological symptoms are progressive loss of memory and cognitive ability, subtle personality changes, inability to concentrate, lethargy, and progressive loss of consciousness. Other neurological symptoms may include tremors, muscle atrophy and weakness, dementia, seizures, and loss of ability to swallow or speak.
Coding Clinic provided a definition in the first quarter of 1988 (pages 3-4):
Leading the question
Clinical documentation improvement specialists continue to have trouble discerning between leading and non-leading physician queries. The question often comes down to an understanding of the various previous “lives” of professionals. Nurses are used parrying over clinical decision making, so why should their queries regarding documentation be any different from the clinical questions they’re used to asking? Quite simply: because there’s money involved.
Sure it’s true just as Robert S. Gold, MD, founder of DCBA, Inc., in Atlanta, said in his
Questions remain over leading queries
article “Is asking for clarification ‘leading’?” that the government never clearly defined the term “leading” and many experts continue to banter over the logistics of the language. However, CDI specialists need to shine a bright light on the differences between the leading and non-leading query to protect themselves and their facilities from the coming onslaught of government auditing agencies.
While the likelihood of true healthcare reform legislation seems to be dwindling, President Barack Obama nevertheless continues to push against apparent payment abuses throughout the system. CDI professionals are meant to be a facility’s first line of defense against such abuses. It a CDI specialist’s job to make sure what was documented in the patient’s medical record is the most accurate description of the care the patient received.
Yet we still hear of facilities focused on Medicare only patients. We still hear about CDI programs directed to only look at records of a certain dollar value. We still hear tales of CDI professionals requesting specific language from physician simply due to some administratively imposed financial quota.
Inappropriate, leading queries, not only open your facility to an inordinate amount of risk but also jeopardize patient care. Generate policies and procedures for your facility that outlines the purpose and intent of your CDI program. Include your administrators, HIM leaders, physician liaisons, and compliance officers in the process. Create standard query forms that allow for the physician to further explain his or her documentation and even to disagree with the reason for the query.
For more information about physician query best practices and the legal architecture on which current query practice is based, read the Physicians Queries Handbook.
Physician Query Handbook released
I think we should throw a party. ACDIS just released the first edition of the Physician Queries Handbook: Guide to Compliant and Effective Communication. I’m not kidding. I’m talking par-T-y. This book is that fantastic. And I was so lucky to I be able to work on it with four wonderful people:
- Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS
Success in a handbook. Simple.
- James S. Kennedy, MD, CCS
- Marion Kruse, MBA, RN
- Lynne Spryszak, RN, CPC-A, CCDS
It’s got cool query audit tools and sample query policies and sample documentation clarification forms but it also outlines various guidances throughout the years and throughout the industry. It provides the pros and cons of verbal and written queries, outlines multiple methods to track query efforts, and offers pointers for conducting effective queries.
Here’s a sample from the book.
A non-leading query clarifies the specificity of current diagnoses and/or procedures based on relevant, pertinent clinical facts within the medical record, such as signs, symptoms, findings, and test results; the treatment rendered including clinical pathways specific to a condition/diagnosis; and the patient’s risk factors including the patient’s current stable conditions, past medical history, medications, and overall risk based on his or her total health status picture. According to the AHIMA physician query practice brief:
“Queries that appear to lead the provider to document a particular response could result in allegations of inappropriate upcoding. The query format should not sound presumptive, directing, prodding, probing, or as though the provider is being led to make an assumption.”
In the following examples of inappropriate queries, the CDI specialist does not give the provider any documentation option other than the specific diagnosis requested. The statements are directive in nature, indicating what the provider should document, rather than querying the provider for his or her professional determination of the clinical facts.
In the first example, the statement “the patient has anemia” may be presumptive, and the statement “please document ‘acute blood loss anemia’” is directive and clearly leads the provider.
In the second example, the CDI specialist inappropriately asks the physician to document chronic respiratory failure. In the third example, the CDI specialist introduces new information not previously documented in the medical record. This is also inappropriate in a provider query. If this diagnosis was not documented in the current admission and is not affecting the patient’s care, it does not meet the definition of a secondary diagnosis. Querying for this new information, which does not meet coding and reporting requirements, is inappropriate.
Query tip for principal diagnosis of fall admissions
by Joel Moorhead, MD, PhD
An article from the Journal of Trauma in 2006 documented that there are more than 770,000 yearly hospital admissions after falls—45% of all hospital admissions for trauma. A fall is surely the most common principal diagnosis that presents coding problems—even when there is clear physician documentation.
Attending physicians sometimes document ‘fall’ as a principal diagnosis but do not identify any specific cause(s) for that fall. However, coders cannot assign a code for a principal diagnosis without knowing what caused the fall, so keep these guidelines in mind:
- Select a principal diagnosis from established conditions the physician has clearly documented.
- Query the physician to obtain a principal diagnosis when documentation is not explicit.
Then, when querying a physician for more detail keep in mind a number of important factors. Falls are often multifactorial, due in equal measure to more than one established condition. When multiple conditions are eligible candidates for principal diagnosis, ICD-9 coding guidelines are clear that coders can sequence any of them as the principal diagnosis. However, when appropriate, ask the physician to clarify whether the documented causes equally contributed to the fall or whether one of the established causes is the principal diagnosis.
Nevertheless, the physician may not know the answer to the query. He or she may not know how that patient fell and received his or her injuries. So provide the physician an opportunity to say that he or she is unable to determine the answer to the query. This guideline is problematic when the coder cannot assign a code for the principal diagnosis directly from physician documentation. A coder’s health information management department may have a policy on whether or not to include an ‘unable to determine’ response option in queries for a principal diagnosis.
When a physician doesn’t reply to a query despite respectful encouragement, review the medical record carefully to determine whether the existing documentation sufficiently supports any established condition as the principal diagnosis.
Editor’s note: This post was adapted from our sister publication JustCoding.com. Joel Moorhead, MD, PhD is an adjunct assistant professor at the Rollins School of Public Health at Emory University in Atlanta. He is also a physician reviewer for FairCode Associates in Towson, MD. E-mail him at jmoorhe@sph.emory.edu.
More on potential pitfalls of malnutrion documentation
Johns Hopkins’ Bayview Medical Center in Baltimore agreed to pay nearly $3 million to settle
Make physician documentation regarding malnutrition a matter of black and white.
allegations by two of its inpatient coders that the hospital’s physicians reported secondary diagnoses of malnutrition or acute respiratory failure not identified or treated, according to a June 30 2009 press release from the United States Attorney for the District of Maryland.
The two coders, whose primary responsibility included assisting with clinical documentation, claimed they were asked to review inpatient medical records to determine whether the hospital could increase reimbursement by changing the severity of certain patients’ secondary diagnoses. Bayview denied all allegations but agreed to pay the settlement to avoid further litigation. How can you ensure compliant documentation for these conditions and avoid becoming the target of a lawsuit?
The following ICD-9-CM codes denote malnutrition:
- 263.0, malnutrition, moderate
- 263.1, malnutrition, mild
- 263.2, arrested development following protein-calorie
- malnutrition
- 263.8, other protein-calorie malnutrition 263.9, unspecified protein-calorie malnutrition
These codes are quite specific and require the physician to document the malnutrition severity. Coding Clinic, fourth quarter 1992, reiterates this point. When coding malnutrition, look for clinical indicators such as lethargy, constipation, skin lesions, and hair loss. Potential treatment for this condition includes calorie counts, daily weigh-ins, and dietary consultations. (Note: These lists
are not comprehensive.)
“I would always look for a dietary consult,” says Kathy DeVault, RHIA, CCS, manager of professional resources at the American Health Information Management Association in Chicago. Coders may not use the dietitian’s notes when assigning codes; however, they can use them as the rationale for submitting a query to the physician.
Related reading:
Look beyond query numbers for program assessment
Now is no time for finger pointing!
The case mix index is up and admissions continue to rise. You’d think this was wonderful news. Yet, the facility administration complains that reviews are down and queries are low. You don’t have to be a math genius to know that something here does not compute.
Is the education given to physicians and allied health professionals being evaluated? Does anyone evaluate the improvement in documentation?
Numbers are classically low in the summer months in Florida due to the absence of our much loved snowbirds from Canada. Vacations from both CDI professionals and physicians take a toll on productivity. New residents start in July, and the heat index rises to 98 degrees (and I don’t mean the literal temperature, either).
Help! How do you rate the success of your clinical documentation department?
Query response rates are evaluated and the overall numbers of reviews are counted. The revenue elicited from these queries is tallied and viola, the success of a program is in the financial numbers. Wrong!
CDI specialists spend a good deal of their day speaking to physicians and educating them on the benefits of proper documentation. They attend huddles with case management, they are members of committees, they round with specialty teams, and they frequently make presentations at meetings and resident Grand Rounds. Does this not count for anything? There needs to be a better way to evaluate success.
CDI presentations commonly extol the virtues of proper documentation— how it improves mortality and morbidity scores and severity of illness statistics. Physician “buy-in” is stressed at every turn, but where and when do we get to discuss the importance of the hospital administration’s “buy-in?”
CDI at Bat
The outlook wasn’t brilliant for the CDI that day:
The chart stood unattended, with one hour left to stay,
Even the best documentation specialists strike out once in a while.
And then when Dr. Cooney didn’t chart, and Dr. Barrow did no more,
A pall- like silence fell upon the patrons of the floor.
A straggling few got up to go in deep despair. The rest
Clung to the hope which springs eternal in the breast:
They thought, “If only Dr. Casey could get a whack at that,
We’d put up even money now, with Dr. Casey at the bat.”
There was ease in Dr. Casey’s manner as he stepped into his place:
There was pride in Dr. Casey’s bearing and a smile lit Dr. Casey’s face.
And when, responding to the query, he lightly doffed his hat,
No stranger on the ward could doubt ‘twas Dr. Casey at the bat.
The usual sneer had fled from Dr. Casey’s lips; his teeth clenched in rage:
He pounded with cruel violence his pen upon the page.
And now the nurse she holds the query, and now she lets it go,
And now the air is shattered by the force of Dr. Casey’s NO!
Oh, somewhere in this favored land the sun is shining bright,
The band is playing somewhere, and hearts are light,
And somewhere men are laughing and little children shout;
But there is no joy at the hospital – mighty Dr. Casey had struck out.
Breaking documentation bad habits
A documentation specialist and I were doing rounds on a unit one day when we ran into a physician who left a query unanswered.
The CDI whispered in my ear:
“I query him about this condition all the time and he usually writes it but I don’t get why he won’t write it without being asked first.”
The physician’s response was simply “out of sight, out of mind.” After a lengthy discussion regarding long standing documentation habits, we realized that this physician wasn’t being non-compliant or difficult—he truly needed the constant reminders. He had developed a pattern of dictation he reverted to whenever looking at a patient’s chart and was in a time crunch.
So this begs the question, how do we change documentation habits and patterns? Do we have any real hope of changing them at all?
For many CDI specialists posting queries is not enough to change a physician’s documentation behavior. Probably the best answer to this question is to keep clinical documentation information in front of physicians. Constant reminders through informational/educational opportunities that are updated monthly can be very beneficial. The format needs to be applicable to the physicians and can vary from hospital to hospital. I caution that once you establish a format be consistent in your approach.
Possible strategies include:
- monthly newsletters
- posters and flyers in the physician lounge
- cue cards that can be easily carried in a pocket and presentations at meetings
But probably the most beneficial method for providing support for documentation that reflects the severity of illness of the patient is for a CDI specialist to be visible on the units when the physicians are on the units. I can’t stress enough the need for personal one-on-one time with the physicians on the floor, the importance for a CDI specialist to be “in their face.”
Pick a CDI topic of the month and go with it. The information needs to remain simple and to the point so you don’t lose the interest of the physician. Again, time is money in their mind so they tend to be more accepting when you get straight to the point. And don’t be afraid to recycle what you’ve used in the past, as reinforcement of new habits is also very beneficial in supporting clear and consistent documentation.
To lead or not to lead: Forming compliant queries
“Whether tis nobler in the mind to suffer
the sling of outrageous fortune,
or to take arms against a sea of troubles,
and by opposing, end them.”
~Hamlet, Act III, Scene I
Shakespear as CDI? Hummm. . .
I truly think that Shakespeare was a frustrated CDI nurse.
I was not fortunate enough to attend the annual ACDIS convention in Las Vegas, but my colleagues let me read through their books. The AHIMA practice brief baffled me when it was introduced in 2008. Has anyone read this carefully? There is an interesting quote from a CMS memorandum issued on October 11, 2001:
“CMS Position is that a query form should not be leading, and it should not introduce new information not otherwise contained in the medical record.”
If a physician documents that a patient has hemoglobin of 5, how can anyone query for anemia if use of the word anemia is prohibited? Furthermore, query forms should not have the name of the condition, diagnosis, or procedure unless such was already listed in the medical record.
Any nurse who works in a hospital intensive care unit has seen the vent setting carefully listed on the record with no mention of the patient being intubated or why. How can a CDI clarify acute respiratory failure and the intubation procedure without mention of the vent, the endotracheal tube or the possible causative diagnosis?
I can understand phrasing the query in a question format (after all I grew up watching Jeopardy): “What is the underlying diagnosis?” I can also understand the rationale for not phrasing the question in a “Yes” or “No” manner. I would not want a physician to say “yes” and then not document anything on the progress note. This is self explanatory. What I have a hard time understanding is what appears to be the systematic torture of physicians who are exposed to ambiguous clarification forms.