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.
Q: Can a patient have encephalopathy after surgery? For example, a patient becomes confused post-surgery and is transferred from the medical-surgical floor to the intensive care unit, where he or she receives high doses of pain medication via IV. However, the patient recovers well and the confusion disappears after the IV fluids and reduction in pain medication and oxygen. Would it be appropriate to query the physician regarding encephalopathy and its possible cause, or would this be a red flag for auditors? The situation did extend the patient’s length of stay by one day.
A: I wouldn’t necessarily query for encephalopathy in this situation. However, I might ask whether the patient had “acute confusion” or “acute drug-induced delirium and/or hypoxia due to narcotics,” and I would want the physician to clearly link the condition to the underlying cause.
Definitions of encephalopathy are easily found by performing a search on the Internet. One such definition, from MedicineNet.com states:
“Encephalopathy: Disease, damage, or malfunction of the brain. In general, encephalopathy is manifested by an altered mental state that is sometimes accompanied by physical changes. Although numerous causes of encephalopathy are known, the majority of cases arise from infection, liver damage, anoxia, or kidney failure. The term encephalopathy is very broad and, in most cases, is preceded by various terms that describe the reason, cause, or special conditions of the patient that leads to brain malfunction. . .”
When an altered mental state is due to a reversible cause (e.g., drugs), the specific condition is what should be reported. The situation you describe sounds potentially like an adverse effect of medications more than encephalopathy. Report an adverse effect by coding the condition (e.g., confusion, delirium, somnolence) along with an additional code (E935.2, Other opiates and related narcotics: codeine [methylmorphine], morphine, opium (alkaloids), meperidine [pethidine]) and indicating the adverse effect of the drug.
Reporting encephalopathy as the only MCC could also trigger an audit. Assigning the most appropriate descriptor (e.g., confusion, delirium, hypoxia) as the adverse effect and ensuring that the documentation clearly links the condition and the cause is important. That way, the record is clear. As the above definitions states, most cases of encephalopathy are due to underlying diseases rather than anesthesia. Another definition from Mosby’s Medical Dictionary states:
“Encephalopathy: any abnormal condition of the structure or function of brain tissues, especially chronic, destructive, or degenerative conditions, as Wernicke’s encephalopathy or Schilder’s disease.”
Both the above definitions appear to agree that encephalopathy is due to underlying disease pathology rather than being a reaction to anesthesia or medication.
In the current climate of increased audit scrutiny I would never query for encephalopathy without also asking for the etiology: “encephalopathy due to…” First, this allows the coder to assign the most appropriate ICD-9-CM code. Second, since encephalopathy is often a source for provider queries and may result in the only MCC on a record, I recommend that CDI staff also query for the etiology as this may provide additional support for the diagnosis.
Editor’s note: Lynne Spryszak, RN, CCDS, CPC, an AHIMA-approved ICD-10-CM/PCS trainer and independent HIM consultant based in Rosell, IL, answered this question, which was originally published in CDI Strategies.
This answer was provided based on limited information submitted to HCPro, Inc. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.
According to AHIMA, the query process has become a common communication and educational method to advocate proper documentation practices to ensure data accuracy and integrity. Queries may be made for the following situations:
- Clinical indicators of a diagnosis but no documentation of the condition
- Clinical evidence for a higher degree of specificity or severity
- A cause-and-effect relationship between two conditions or organism
- An underlying cause when admitted with symptoms
- Only the treatment is documented (without a diagnosis documented)
- Present on admission (POA) indicator status
Definition of a Query:
A question posed to a provider to obtain additional, clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes in the patient’s health record.
Whom to Query?
Any physician or other qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis, including
(Attending Physician, Consultants, Specialists, Emergency Physician, Anesthesiologist, CRNA, Intern, Resident, Fellow, Physicians Assistant, Podiatrist , Nurse Practitioner). When there is conflicting information, the attending physician should be queried since he/she is ultimately responsible for the final diagnoses.
When to Query?
When there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure.
AHIMA states that a query may be appropriate when documentation in the record fails to meet one of the following five criteria:
- Completeness (abnormal results without comment)
- Clarity (cause of symptoms)
- Consistency (disagreement/conflicting info)
- Precision (more specific)
When Not to Query
- Codes assigned to clinical data should be clearly and consistently supported by provider documentation. Coding Clinic 2000 Q2 P 17: “When documentation in the medical record is clear and consistent, coders may assign and report codes.”
- Queries should not be used to question a provider’s clinical judgment, but rather to clarify documentation when it fails to meet the five criteria: legibility, completeness, clarity, consistency, or precision.
- In situations where the clinical information or clinical picture does not appear to support the documentation of a condition or procedure, hospital policies should provide guidance on a process for addressing the issue without querying the attending physician.
Editor’s Note: This post is an excerpt from the 2012 CDI Pocket Guide by Richard D. Pinson, MD, FACP, CCS, and Cynthia L. Tang, RHIA, CCS.
There was an excellent conversation string started on CDI Talk a couple of days ago about productivity measures and staffing models. I provided one of my typical responses there and realized that it might be worth developing into a quick, short(er) post.
The original question asked about daily expectations for an individual CDI specialists as far as initiating new cases and following up on existing cases, as well as expectations for reviews per number of discharges per year.
A lot of excellent replies, comments and sharing followed. I do shy away from quoting any specific response (you know just like Vegas, what happens on CDI Talk stays on CDI Talk), but one of the repeated observations was how difficult it is to come up with a single figure of merit due to a number of program variations such as:
- number of individuals
- program focus
- paper vs electronic record (and which electronic record system a facility uses)
- physician collaboration
- CDI staff experience level and learning curve
- additional roles/focus (ROM/SOI, POA, RAC, core measures, etc.)
- complexity of patients
There are few (if any) true benchmarking resources that I have found outside of ACDIS. Consultants certainly have their own models but that is not the same as an objective “what is being achieved”. All three of the following are worth reading carefully.
- 2010 Physician Query Benchmarking Report
- 2010 CDI Program Benchmarking Survey
- April 2010 White Paper on CDI Staffing Survey : The respondents to this survey were mostly managers or leaders and only one response per hospital was permitted. This report also nicely summarized discussions by the CDI Work Group about factors that affect CDI productivity.
- For an annual volume of discharges, the on-line poll (#36, Dec 2008) suggests a median of around 1,700 discharges/year/CDS. It shows an interesting distribution, with a big peak at >2,500, and then the next high point the two elements between 1,300 and 1,900. There are other on-line ACDIS polls that also provide some insight.
Let me briefly summarize some of the ACDIS survey data. I will use the 2010 Physician Query Benchmarking Report, though the other sources generally agree.
Items that influence productivity:
- Frequency of concurrent review: 58% daily, 24% every other day.
- Majority of queries: 63% written paper based, 20% written electronic, 3% verbal, 12% equal mix written and verbal
- Do you query when there is not a financial impact: 43% always, 44% frequently
- Do you use templates for written queries: 31% always, 36% frequently, 16% sometimes, 13% never.
Direct productivity benchmark measures:
- Do your CD I specialist’s have a set query quota to meet: 56% no, 38% yes (the median point for that query quota appears almost 25% queries).
- Median query rate about 18%
- Median physician response 87% (with a clear break for >70% suggesting an absolute minimum)
- Median Physician agreement 88% (again, >70%)
- Median new charts per day of 12 (majority between 6 & 25)
- Median repeat reviews per day of 12 (most 6 to 20)
Most sources suggest an average combined total of charts reviewed around 25 charts. Unfortunately, when extrapolating the daily numbers, they don’t match up with what is commonly discussed for an annual productivity model broadly between 1,300 and 1,900 (i.e., 20 to 25 working days a month times 12 new reviews daily times 12 months gets you to >2,400 cases a year).
In my last blog titled Identifying Missing CDI Elements by Expanding Our Horizons, I extolled the virtues of identifying patient medical necessity for inpatient hospitalization and the potential vital role CDI specialists play in working with case management (CM) and utilization review (UR)/management staff.
In this blog post I will focus on offering practical considerations to how to integrate our role as change agents into the daily chart review process.
CDI staff and determination of medical necessity
Clinical documentation serves a number of people and purposes such as:
- Appropriate ICD-9 code and MS-DRG assignment
- Clinical outcome studies
- Reporting of risk adjusted severity of illness
- Readmission as part of the proposed Hospital Value Based Purchasing program
- Quality and efficiency care provisions under proposed rules for Accountable Care Organizations
CDI specialists are also frequently asked to help establish medical necessity for patient admission as well as the medical necessity for a patient’s continued stay in the facility. All of these items depend on clear, concise, accurate, and relevant clinical documentation. I suggest that, as a profession, we stand to expand our presence and elevate our stature in the entire process. [more]
Q: I am looking for help posing queries regarding the specific link between diabetes and conditions typically considered diabetic complications. Should we always query the physician regarding the link between the presenting symptom and the diabetes?
A: A cause-and-effect relationship between diagnoses may not be assumed and coded unless documented as such by the attending physician; therefore the CDI specialist may need to query the physician to ascertain such documentation defining the connection between diagnoses.
A query form may state that fact as an introductory statement, then summarize the patient’s clinical indications according to information from his or her medical record, and prompt the physician to indicate a potential cause-and-effect relationship if clinically appropriate. Here is sample language you might adapt to your facility’s needs:
A cause-and-effect relationship between diagnoses may not be assumed and coded unless documented as such by the attending physician. The patient presented with ___________ (“neuropathy”, “diabetes”, and “CKD” as documented in the H/P.). Please document the cause-and-effect relationship, if any, between these conditions and the patient’s diabetes using one (or more) of the following examples as clinically appropriate:
- Diabetic foot ulcer
- Diabetic CKD
- Diabetic neuropathy
- Diabetes related: foot ulcer/neuropathy/CKD neuropathy/CKD/foot ulcer due to diabetes
- Other __________________
This is one of those main educational messages (cause and effect) that you’ll want to communicate prior to query dissemination to the medical staff. However, the more consistently you ask this type of question, the sooner providers will get used to documenting that relationship appropriately the first time. In my opinion, repetition and consistency achieves results.
In general, you can always ask: “Is there a cause-effect relationship between the following conditions ______________ and ________________? If so, please document this relationship in the progress notes and discharge summary.” Then give appropriate options similar to the ones I listed above.
Some other examples where cause-effect queries are necessary include:
- Hypertension and heart disease
- Diabetes and any associated complications (neuro, vascular (PVD), eye, kidney, etc.)
- Sepsis and localized infection
- Complications of malignancies (obstruction due to, respiratory condition due to, etc.)
If you base your query policies using AHIMA guidance documents you should be in good shape, but always have any query templates approved by your compliance officer and/or legal counsel before you start using your queries.
My opinion is that there’s nothing inappropriate in telling the providers why you’re asking the question. In this case, you’re giving them the coding rules, which they did not previously know.
Editor’s Note: Lynne Spryszak, RN, CPC-A, CDI Education Director for HCPro Inc., Danvers, MA, answered this question. Spryszak teaches the CDI Boot Camp and its online version.
The American Hosptial Association Coding Clinic cites numerous instances where coders are instructed to query the physician so it is important that you have the tools to do so. That’s why ACDIS members graciously donate samples of their query forms for the association to post on the Forms & Tools Library.
The latest batch of queries comes from Susan A. Klein, BSN, RN, C-CDI, director of clinical documentation management at Saint Peter’s University Hospital in Monroe Township, NJ. Klein included query samples regarding:
- staging for chronic renal failure
- unspecified chest pain
- congestive heart failure
- debridement documentation
Although Klein expects to update her congestive heart failure form to include some core measures information in 2011 the sample provided does offer an interesting checklist of potential diagnoses that could increase the specificity of the medical record. Klein created the forms herself, based on her experiences in CDI and the documentation improvement program she implemented at SPUH. Each form was discussed at its respective medical division and approved by the facility forms committee and medical record committee for their approvals as well.
As with all the forms and other items included in the ACDIS Forms & Tools Library, Klein’s donations are intended as a sample only and any diagnostic criteria should meet the approval of your medical staff and compliance team. “As you know every hospital is unique,” says Klein. “This works well for us here.”