All Entries Tagged With: "query"

Q&A: Potential post-surgical encephalopathy

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.

Book Excerpt: Clearly establish your program query processes

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
  

  The 2012 CDI Pocket Guide.

• 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:

1. Legibility
2. Completeness (abnormal results without comment)
3. Clarity (cause of symptoms)
4. Consistency (disagreement/conflicting info)
5. 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.

CDI Productivity Benchmarks (A CDI Talk topic)

ACDIS surveys, reports, and polls, can help answer productivity questions.

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).

Expanding the CDI Horizons: Practical Considerations

If you look at the center of this illusion it looks like the circles at the corner are expanding. Expand. That's what you want to do with your CDI program.

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&A: Querying for the link between diabetes and diabetic complications

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:

Make sure physicians link the cause-and-effect relationship between conditions.

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 __________________
• Undetermined

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.

New sample query forms posted

Check out the latest sample query forms at www.acdis.org

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.”

SE MLN Matters article addresses concerns found by RAC

A Special Edition MLN Matters article released last week points to two overarching concerns leading to RAC claims denials–lack of timely submission of requested documentation and lack of documentation supporting medical necessity.

On July 12, CMS released what it called “the first in a series of articles that will disseminate information on RAC high-dollar improper payment vulnerabilities.”

CMS states that due to the implementation of the permanent RAC program and the initiation of complex medical review (coding and medical necessity), that it is currently more important than ever for providers to understand the lessons learned from the ongoing RAC audits and implement appropriate corrective actions.

CMS has provided a list of requirements to assist providers in ensuring the timely submission of sufficient documentation to justify the services billed, which Hoy says is a useful listing of what the provider can expect of the RAC. One particular statement though, “RACs must clearly indicate in ADR letters suggested documentation that will assist them in adjudicating the claim,” stood out to Hoy.

“It’s interesting that CMS calls the information requested by the RAC ‘suggested documentation,’ because there’s been an issue of whether or not coding queries have to be submitted,” she says. “CMS stated on an implementation call that these queries only have to be submitted if they supported a claim, and this seems to be in line with that.”

To view Special Edition MLN Matters article SE1024, click here: http://www.cms.gov/MLNMattersArticles/downloads/SE1024.pdf

Good gossip: AHIMA readies to release new query brief

We don’t know when it is going to be released or what it is going to cover but we have heard that AHIMA plans to release its latest attempt to offer guidance for clinical documentation improvement specialists and the query process soon.

Four members of the ACDIS Advisory Board participated on the AHIMA CDI Work Group throughout 2009 calendar year and although they have to keep mum on the content of their efforts until the association makes its formal release, I thought it might be worth a post under the heading of “good gossip.”

Are there items you wish the new brief would address? Let me know your thoughts by posting a response here.

Personally, I’d like to see a little more definition around the process of verbal queries and how the roles and responsibilities of the CDI nurse differ (or don’t) from the coding specialist. Remember the initial AHIMA guidance technically acts only as guidance and primarily addresses the query habits (and requirements) of the coding staff.

Although the ACDIS board members aren’t spilling any details they did say they’re proud of the AHIMA CDI Work Group’s efforts and feel the information will be helpful to CDI teams when it is released.

Chicago CDI Boot Camp sold out

That’s the good news and the bad news, I’m afraid.

On the good news side of the scale we place the fact that 32 people—that’s right, 32 people—registered for the four-day CDI Boot Camp being held at the Marriott Courtyard in Chicago/Schaumburg September 28 through October 1. The number of registrants speaks to the intensity of the educational needs of the profession as well as to the dedication of CDI professionals.

Of course, on the bad news side of the scale we place the fact that the Chicago program is, in fact, sold out. So anyone in the area who had hoped to register but was perhaps waiting for last minute approval from their director or other supervisor missed out, I’m afraid. We hope that if you’re in Chicago and did get shut out of the Boot Camp, you’ll be able to take some solace in the fact that the 2010 ACDIS conference will be held in the Windy City June 3rd and 4th, with the pre-conference coding essentials program and post-conference CCDS exam.

Just one more item to tip the scale to the positive. (I like to leave things primarily on a positive note, if possible.) Just because the Chicago program is closed doesn’t mean there won’t be other learning opportunities. The Atlanta, GA, program taking place at Hyatt Place October 12-15, still has multiple open slots. Just a note on that, the early bird hotel room rate ends on September 18, so if you are interested you might want to mention that to the powers that be.  And the Boot Camp taking place at the Hilton Phoenix Metro Center in November from the 2nd to the 5th also has multiple slots open.

We are in the planning stages for the 2010 Boot Camp schedules now so if you want a session to come to your neighborhood, give us a shout. We hope everyone who attends the Chicago intensive has a great time and learns a lot.

Chemotherapy documentation challenges warrant CDI attention

Given the extremely high cost of chemotherapy services, it is likely that third-party payers, including Medicare, will scrutinize these services, says Glenn Krauss RHIA, CCS, CCS-P, C-CDIS, in an article for JustCoding.com.

Here is a breakdown of areas generally targeted by payers including Medicare and their related documentation difficulty:

• Medical necessity for the supplied diagnosis: Often the clinician fails to provide the specific location of the cancer. A clinical documentation specialist can query the physician to ensure appropriate documentation.
• Coverage exclusion for specific drugs based on clinical trial effectiveness:  Coders should reference local coverage determinations that generally spell out which diagnoses are considered covered benefits for common chemotherapeutic agents.
• Proper charging and billing of drug units: Just documenting patients’ nausea and vomiting is not always sufficient to support payment of anti-emetic medicines.
• Documentation to support IV administration units of service: Accurate coding for this requires clear start and stop times for IV chemotherapy administration. It is particularly problematic because clinicians do not always document the order of sequential therapy.

CDI programs might consider designating a team member specifically for the chemotherapy service line, Krauss says. A part-time specialist or member of the existing team may be enough depending on the monthly volume of patients in the chemotherapy department and the number of new patients who begin chemotherapy each month.

Focus initially on validating documentation and providing feedback to clinicians regarding documentation of IV therapy administration. The CDI specialist can help bridge the gap between customary medical record documentation and the level and detail of documentation necessary to properly and accurately capture all IV administration charges.

JustCoding.com subscribers can read the complete article online.