Editor’s Note: CDI Talk is a networking forum for ACDIS members, in which members ask pressing questions and garner the opinion and expertise of their peers. Pediatric CDI Talk is a forum specifically designed for CDI specialists in pediatrics. Join by clicking on the CDI Talk tab on the ACDIS website.
In one recent discussion on Pediatric CDI Talk, users discussed examples of malnutrition and acute respiratory failure query templates, as well as query compliance. The tips are applicable to both adult and pediatric CDI.
A good clarification summarizes the case and presents the clinical indicators are, says Katy Good, RN, BSN, CCDS, CCS, CDI Program Coordinator, and AHIMA Approved ICD-10CM/PCS Trainer at Flagstaff Medical Center in Arizona.
Format-wise, many providers prefer simple bullet points for a quick and easy read, says Good. However, some do prefer a narrative, so it is important for the CDI specialist to find out what each physician would like to see in a query. Good generally uses bullets, but will modify to a narrative approach if the query is unusual or complex, and if the narrative style query is more effective in a certain case.
The problem many CDI specialists face, Good says, is often properly wording and formatting the question(s). Any questions must not lead the physician to a particular diagnosis in any way. For example, the CDI specialist cannot ask the physician if a patient has a particular condition. Instead, they must ask the physician to clarify an existing condition with additional specificity, or ask what condition(s) is being treated. It is appropriate to provide options, Good says, but it is also important to include all reasonable options, and to allow the physician to provide an additional response such as “other” and “unable to determine.”
Here are some example queries (download the forms below under “attachments”). Though this was posted on Pediatric CDI Talk, the example queries are for the adult population, which is reflected in the clinical indicators.
In the first query about a malnutrition case, Good suggests including the clinical indicators used, making sure to note where in the record you found them. Then, ask if the physician can further specify the malnutrition as “mild,” “moderate,” “severe,” “other,” or “unable to determine. Be extremely careful when querying for malnutrition as various government agencies and auditors have targeted malnutrition and related activities. (Read a related article on the matter in the March 5 edition of CDI Strategies.)
The second query deals with clarifying a diagnosis. CDI specialists should never ask the provider if a patient has a certain condition. This could introduce a new diagnosis to the medical record and is considered leading. Try using a multiple choice query instead. For example, “Can you please clarify whether the patient is being evaluated/treated for: Acute respiratory failure, Chronic respiratory failure, Acute on chronic respiratory failure, Other, Unable to determine.”
The following is one example of a possible open-ended query:
“Dear Dr. Phil,
The patient’s sodium (Na) was 129, the progress notes indicate low serum sodium level, ‘¯Na.’ An order was written to place the patient on .9NS. Please clarify the associated diagnosis being treated.”
In this scenario, the physician is highly likely to respond and document “hyponatremia.”
The 2013 ACDIS/AHIMA query practice brief describes an obtruded patient with a history of vomiting treated for pneumonia. The open-ended query asks the type/etiology of the pneumonia, which, in that example, most likely result in a response of “aspiration pneumonia.”
Sometimes an open-ended pneumonia query can be problematic, however. For example,
“Dear Dr. Oz,
The patient’s progress note indicates he is being treated for pneumonia with vancomycin. Please clarify the type of pneumonia being treated.”
Although the wording of this query does a great job of not leading, it may not result in the most clinically appropriate answer (methicillin-resistant Staphylococcus aureus pneumonia). In many cases, the physician will respond “bacterial pneumonia,” which will still lack the specificity needed for coding purposes. Other physicians may respond “complex” or severe pneumonia.
In such situations, the CDI specialist would have to use a second query in an attempt to further clarify the issue. The use of open-ended queries works best when the potential answers are limited, involve commonly used terminology, and when physicians essentially understand the type of documentation required.
Editor’s Note: This excerpt was taken from The Physician Queries Handbook by Marion Kruse, MBA, RN.
Q: We have a problem getting our physicians to understand what we are querying for (chronic respiratory failure) when a patient is on home oxygen continuously with documented supplementary oxygen (SpO2) of <90% or arterial blood gas (ABG) with hypoxemia documented. They tell us Chronic Obstructive Pulmonary Disease (COPD) is chronic respiratory failure by definition. Can you help us clarify this or give us some tips on how to educate our physicians?
A: I see two pieces of education as needed in this situation. First, we need to establish the diagnostic criteria for chronic respiratory failure. Many physicians do consider COPD as chronic respiratory failure. But not every patient with COPD requires continuous oxygen support. Some require oxygen at night only, others only as needed, and others do not require oxygen at all.
If your organization has not developed an agreed upon definition of both acute and chronic respiratory failure maybe now is the time to do so. Work with your pulmonologist to define these terms with examples of the clinical indicators needed to make the diagnosis. These clinical indicators would then be the standards the CDI specialists and coders would use to determine if a query is needed as well. Once you have an agreed upon criteria, you can use it as part of your physician education.
Examples of diagnostic criteria for chronic respiratory might include:
- Persistent decrease in respiratory function
- Chronic continuous home oxygen
- Chronic hypercarbia due to respiratory condition (i.e. pCo2>40)
- Use of chronic steroids for underlying lung pathology
Secondly, physicians need to understand wording such as “end stage lung disease,” “severe lung disease,” or use of the GOLD staging for COPD does not lead to a code assignment that reflects chronic respiratory failure. Using the clinical indicators such as those above, discuss with the physicians that not every person with COPD meets such criteria. Some are more severe than others, and as mentioned above not all require oxygen. Not all require chronic steroid use.
A patient with chronic respiratory failure has a higher severity of illness (SOI) and risk of mortality (ROM). These patients have a much lower threshold to enter acute respiratory failure. They can decompensate very quickly. The physicians may not understand why the wording of chronic respiratory failure is so important.
We need to ensure the physicians understand how important it is to capture the SOI/ROM that accurately reflects their patients’ conditions. This will affect both the quality measures assigned to the organization and to the physicians.
I hope this information helps. Please let me know if you need further assistance and also if you discover a “magic cure” to this documentation issue.
Q: We are struggling with how to query physicians regarding complications of procedures or surgeries. For example, a patient was readmitted for a bile leak two weeks after a cholecystectomy. Neither the attending nor the GI consultant ever stated that this was a complication. Can you give me some suggestions as to how I could word this?
A: It used to be very difficult to construct these types of queries but the 2013 ACDIS/AHIMA physician query practice brief expanded the use of the yes/no query format—and this is the perfect situation in which to use it.
The provider will likely have to respond on the query form when using a yes/no format so the query would need to be part of the medical record. Here is how I would pose the query:
Dear Dr. Bile Leak,
Is there a relationship between the bile leak and the cholecystectomy that occurred two weeks ago?
- Unable to determine
- Other: __________
If you are uncomfortable with the yes/no format or your queries are not kept as part of the medical record, you would pose a query as follows:
Dear Dr. Bile Leak,
Please clarify what, if any, relationship exists between the bile leak and the cholecystectomy that was performed two weeks ago.
- The bile leak is related to the cholecystectomy
- There is no relationship between the bile leak and cholecystectomy
- Unable to determine
- Other: __________
If your query forms are kept as a permanent part of the medical record then let the provider know. If not, be sure to prompt the provider to respond in the next progress note and/or the discharge summary.
You can change the wording to show the relationship between the bile leak and cholecystectomy as I just chose “related to,” but you could say, “secondary to,” “from,” or other such terminology. If the provider is to document on the query form using either of the above formats then you would need to add a place for the provider’s signature, date, and time as the query form must then meet authentication requirements associated with any document within the medical record.
I hope this helps.
At this point CDI has been around for some time. Like most good things, it grows stale after a while, and you need to boost your program with some fresh ideas.
Those working in the CDI field need to think about how we can help physicians with their documentation, in ways that help not only the hospital but the physicians themselves. CDI specialists need to help improving severity of illness (SOI) and intensity of service reporting so that the documentation coincides, and complements, physicians’ Evaluation and Management (E/M) assignment; so the documentation accurately establishes the medical necessity for the patient encounter and the level of service that ultimately gets billed.
There are two distinct E/M codes for day-of-discharge care, or discharge management. The latter two codes are differentiated by the amount of time spent in conjunction with discharge of the patient including:
- patient evaluation
- writing of discharge orders
- medication management
- coordinating care with the case manager and/or social worker
- patient/family teaching
- preparation of discharge paperwork including dictating of discharge summary
The lesser code is 99238 and the greater code is 99239, requiring greater than 30 minutes of physician face-to-face time on the floor carrying out the discharge process.
Q: I am very interested in issues around adjusted hospital mortality rate for stroke, and its use as a quality measure. (I recently read a CDI Strategies article from February 2012, on the matter.) My feeling is that comfort care patients who die (most if not all) should not count against a hospitals rate—as death could be viewed as the natural outcome of the case. Is there any movement to code these comfort care issues so that such adjustments can be (importantly) made?
A: Mortality rates and quality measures are two very different metrics. The calculation of mortality rates will differ depending on who/what organization is calculating the mortality rates.
Many organizations began adding the palliative care code V66.7 to all applicable patients in an effort to exclude these cases from their morality rate; however, most formulas have since been revised because palliative care actually decreases one’s individual risk of mortality. As such, very few mortality modules exclude patients with code V66.7. Depending on the methodology the code associated with palliative care V66.7 has no value in either MS-DRG methodology or APR-DRG methodology meaning they do not affect the final DRG assignment.
The formula used by US News and World Reports in 2009 did include V66.7 into its risk adjustment, but I’m not sure how much impact this code has within the model. Basically, the addition of code V66.7 has little impact within coded data in regards to reimbursement or mortality metrics.
Regarding CMS quality measures, referred to as “core measures,” CMS is responding to the increasing use of V66.7 and looking to differentiate those who are near death from those who are receiving palliative care. There is no set time frame associated with placing someone on palliative care. Although Medicare hospice benefits require the beneficiary to have a life expectancy of six months to qualify, there is no penalty if the patient survives the initial six months. In fact, many patients have spent years receiving hospice services. As such, CMS further realizes that the designation as a “hospice” patient is also a poor predictor of being “near death.”
Coders have received guidance that code V66.7 is to be used when the provider uses the terms, “comfort care,” “end-of-life care,” or “hospice care.” Part of the problem is that code V66.7 is nonspecific, what I mean by that is you don’t necessarily know which condition qualifies the person for palliative care. For example, one can be on palliative care for Alzheimer’s disease, but also be admitted to the hospital for an exacerbation of systolic heart failure.
So just because this patient is on palliative care for the Alzheimer’s does not mean they should not receive best practice treatment for the heart failure, which is a CMS quality measure diagnosis. As such, the patient would not be excluded from the CMS measures for heart failure just because they are receiving palliative care. If, however, the patient is only receiving end of life care for the Alzheimer’s, then it makes sense that the patient would not receive care for the heart failure as this treatment becomes irrelevant at that point.
So to answer your question, code V66.7 is used very liberally and is associated with palliative care, which is not the same as comfort care only. No, we cannot currently capture “comfort care only” based on the current codes available in ICD-9-CM (or ICD-10-CM). When the provider documents comfort care only, then the V66.7 code would be assigned and the case would be excluded from CMS quality metrics if the chart is abstracted. The CMS quality metrics associated with stroke can be found on www.qualitynet.org.
There is a new code associated with “do not resuscitate” (DNR) – V49.86, but this also has no value with the MS-DRG or APR-DRG system and currently doesn’t have any impact within any mortality methodologies at this time. Now, to confuse you even more these CMS quality measures are not the same as the AHRQ Patient safety indicators so currently there is no exclusion to any of these indicators for either V66.7 or V49.86. It is important to know which “quality” metrics your facility is tracking and attempting to affect with your CDI efforts.