Query forms themselves in many cases will help start ICD-10-CM/PCS-related conversations and educational opportunities with providers. Medical staff should be involved in the ongoing creation and review of query forms.
As is the case with ICD-9-CM, the medical staff most closely linked to a particular condition should vet the clinical guidelines incorporated in the query forms as you adapt them to ICD-10-CM/PCS. Many facilities have clinical guidelines to help determine types of congestive heart failure (CHF) based on recent medical literature and as supported by the cardiology department.
The CDI team at [more]
Q: I have been asked to build a query for a diagnosis of SIRS and/or sepsis for the following scenario: The patient was admitted for an infection urinary tract infection (UTI), Pyelonephritis (PNA) and meets two SIRS criteria. The patient may be treated with oral or intravenous antibiotics, and may be on a general medical floor (not intensive care). The physician did not document SIRS or sepsis. I am having a hard time with this query because I am not sure if this would be considered adding new information to the chart, leading the physician, by introducing a new diagnosis. Do you have any suggestions?
A: Although many CDI and coding professionals feel offering a new diagnosis as a choice in a multiple choice query or clarification is considered introducing new information, the 2013 Guidelines for Achieving a Compliant Query Practice states,
“[P]roviding a new diagnosis as an option in a multiple choice list, as supported and substantiated by referenced clinical indicators from the health record, is not introducing new information.”
Thus, if you have a patient that demonstrates clinical indicators to support the diagnosis of sepsis, you may submit a query to clarify if this diagnosis is appropriate. In the body of the query, you would also include those clinical indicators and evidence of treatment that supports your rational for querying the physician.
That said, use the SIRS criteria to support sepsis, with caution. The criteria cannot be explained by another existing condition—for example, tachycardia when the patient has atrial fibrillation. Review the Surviving Sepsis Campaign’s nationally supported clinical criteria and treatment bundles that can be used to support the diagnosis of sepsis.
Here’s an example query that you might use:
Patient 2345 was admitted with a UTI. The ED record indicates patient was febrile with a temperature of 102.7, heart rate of 98, Laboratory results showed a white blood cell count of 13,500 with 12% bands, hyperlactatemia, and altered mental status. Blood cultures pending. Antibiotics ordered with fluid bolus.
Based on these clinical indicators, can the patient’s status be further clarified as:
- UTI with sepsis
- UTI only
- Other _____________________
- Unable to determine
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.
Q: If the physician says “concerning for,” “considering,” “cannot be ruled out,” or “cannot be excluded” for a diagnosis is that considered an uncertain diagnosis? Can those terms be coded if the patient is being worked up? Are the terms “concerning for” and “considering” equal to the “uncertain diagnosis” terms “yet to be ruled out?”
A: Yes, the terms “concerning for” and “considering” would be interpreted as an uncertain diagnosis, so they would only be reportable if they appear at the time of discharge. The Official Guidelines for Coding and Reporting doesn’t limit the terminology that can be associated with an “uncertain” diagnosis. It states:
“If the diagnosis documented at the time of discharge is qualified as ‘’probable,’ ’suspected,’ ‘likely”, ‘questionable’, ‘possible’, or ‘still to be ruled out’, or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.”
Note: This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.
The AHA’s Coding Clinic for ICD-9-CM/ICD-10-CM/PCS has also addressed this topic. Encourage providers to use the phrase “evidence of” when they feel comfortable that a diagnosis is relevant, but may be lacking certainty through diagnostics. Please see below (the text is taken from slides featured in our CDI Boot Camp):
Querying for Organism:
- Coding Clinic 3rd Quarter 2009 provides clarification regarding use of the verbiage “evidence of”
- When the provider documents “evidence of” a particular condition, it is NOT considered an uncertain diagnosis and should be appropriately coded and reported.
- If the provider documents “evidence of” a condition and/or causative organism in the progress notes or on a query, a code can be assigned without further documentation; however, the CDI should monitor the record for evidence of the condition being ruled out and query the status of the diagnosis if applicable.
Coding Clinic ICD-10-CM 1st Qtr. 2014
- Is it appropriate to report codes for diagnoses reported as “evidence of cerebral atrophy” and “appears to be a nasal fracture,” …
- ANSWER: The phrase “appears to be,” listed in the diagnostic statement fits the definition of a probable or suspected condition and would not be coded in the outpatient setting… However, when the provider documents “evidence of” a particular condition, it is not considered an uncertain diagnosis and should be appropriately coded and reported…
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: 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 firstname.lastname@example.org. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview.
Have you booked your hotel room for the annual conference? You may have heard that we’re sold out of our original number of hotel rooms. But don’t worry, we’ve got you covered. We’ve contracted an additional block of rooms at the Grand Hyatt San Antonio, which is just around the corner from the convention center. Reservations may be made individually through the hotel’s reservation department by calling 888-421-1442 or 800-233-1234 and mentioning ACDIS.
Room rates are $199 for single or double occupancy; $225 for triple occupancy; and $249 for quadruple occupancy. These prices do not include applicable taxes, service fees, and/or hotel-specific fees. The cut-off date for reservations is April 24—reservation requests received after that date will be based on availability at the hotel’s normal rates.
Even if you haven’t started planning your itinerary, we’re previewing a handful of speakers throughout the coming weeks to give you a feel for the sessions. This week, we spoke with Millie G. Alexander, RN, BS, CCDS, a senior managing consultant at Berkeley Research Group in Hunt Valley, MD, who will be presenting “Clinical Evidence Queries: Tips, Tricks, and Caveats.”
Q: Why is it important to understand clinical evidence?
A: Prior to the release of the 2013 Guidelines for Achieving a Compliant Query Practice, CDI specialists and coders were told to never question physician documentation because doing so meant that we were questioning the physician. The new brief suggests otherwise; it instructs CDI specialists to always use existing clinical evidence to formulate queries and when lack of clinical evidence exists, to query the physician for alternative diagnoses and/or documentation.
Q: How is your topic important for everyone in the CDI role, regardless of professional background?
A: This topic addresses the evolution of CDI practice. Clinical evidence is what is cited by federal, state, and commercial auditors as the reason for denials, so it’s important that we’re all aware of how it is used.
Q: As an RN, how does your perspective differ from other professionals performing the CDI role?
A: A RN has not only clinical knowledge, but also what I call “trench” knowledge. An RN thinks in clinical scenarios, and this depth of experience can sometimes enrich the practice of CDI.
Q: What do you think is the most important quality for a CDI professional to have?
A: Integrity and humility go hand in hand. When I teach, I not only bring out my own humble pie, but I tell my students to always have a case of humble pie on-hand. We are in an evolving practice, and cannot know what we do not know. This form of integrity of being totally real has enabled me to be a student and a teacher at the same time.
Q: What are you most looking forward to at the ACDIS conference?
A: The conference is a “pump you up” experience and is reinforcing to our practice. CDI is still controversial to some physicians and to some hospital administrators. I personally love working our booth and meeting new folks, and seeing former students.
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.