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3rd Annual
Association of Clinical
Documentation
Improvement
Specialists Conference
Gray Areas in CDI:
Negotiating the Relationship
James S. Kennedy, M.D., C.C.S.
Managing Director
FTI Healthcare
Speaker
• James S. Kennedy, M.D., C.C.S.
– Managing Director, FTI Healthcare
• CDCI Practice Leader
– Medical School – University of Tennessee
– Private Practice – General Internal Medicine,
1983–1998
– CCS Certification – 2001
– Publications:
• 2007–current – “Minute for the Medical Staff” in Medical
Records Briefing
• 2008 – Severity-Adjusted DRGs, an MS-DRG Primer
• 2009 – Physician Query Handbook
Disclaimer
•
•
•
•
The information presented reflects Dr. Kennedy’s understanding of the ICD-9-CM and his
wish that all medical conditions addressed during a clinical encounter are documented
accurately in the medical record by providers and coded compliantly by the coding staff.
Dr. Kennedy and FTI Healthcare wholeheartedly support ICD-9-CM, its Guidelines, its
interpretations through Coding Clinic for ICD-9-CM, and other applicable laws or practice
standards. Coders, clinical documentation specialists, and physicians are expected to be
familiar with applicable rules, regulations, and laws, implementing them in their daily work.
It is not the speaker’s nor FTI’s intent or desire that any physician, case manager, or coder
promote diagnosis terminology that is not supported by a reasonable standards of care or
appropriate physician literature, nor is it their intent to encourage coding or query practices
that fraudulently or abusively incur incorrect payments under government or private
insurance programs.
This lecture is highly clinical and reflects the opinions of a clinician discussing clinical
syndromes. Nothing said in this lecture should be construed as medical advice.
The audience is strongly encouraged to discuss the content of this lecture with their
compliance officer prior to submission of claims for payment to any healthcare insurer or
government entity. Dr. Kennedy, FTI Healthcare or other entities affiliated with this lecture
will not assume responsibility for any misunderstanding or misapplication of the material
presented in this lecture.
Goals
• Review certain “gray” areas surrounding
concurrent and retrospective provider query
– Principal diagnosis sequencing
– Coding of uncertain diagnoses
– Coding and query in the absences of a discharge
summary
– Definitions of “leading queries”
– Differing roles of licensed and unlicensed
personnel in provider query
– Postoperative complications
Note – Due to time limitations, other topics outlined in the promotional brochure may not be covered. If
there are any questions, please contact the author directly for further support.
Clinical Scenario #1
• An 80-year-old white female presents to
the hospital as an inpatient for pneumonia.
She currently lives in a skilled nursing
facility due to a left hemispheric stroke
sustained two weeks prior to admission
resulting in a dense right hemiparesis and
an expressive aphasia. She is being fed
with a nasogastric feeding tube.
Clinical Scenario #1 (cont.)
• Her past history is otherwise insignificant. Current
medications consist of tube feeding, aspirin,
Plavix, and multi-vitamins.
• Physical examination on admission has a
temperature of 100.5°F, pulse of 90, RR of 24,
and BP of 135/70. Generally, she is aphasic and
has some raspy respiratory and requires
suctioning, producing purulent sputum. She has
rales and bronchial breath sounds in the RLL. NG
tube is in place. There is a dense right
hemiparesis with hyperreflexia. The rest of her
examination is noncontributory.
Clinical Findings
• WBC 9,800 with 10% Bands.
• O2 sat – 98% on RA
• Sputum gram-stain shows multiple
organisms.
• Chest X-ray with RLL infiltrate
• Admitting impression:
– Healthcare-associated
pneumonia
– Recent stroke with right
hemiparesis and aphasia
– Dysphagia
•
Photo source: CDC – Emerging Infectious Diseases – Public Domain
Available at: http://www.cdc.gov/ncidod/eid/vol6no1/scrimgeourG2.htm
Rx: Zosyn, vancomycin,
tobramycin.
Pulmonary toilet
(e.g., CPPD, aerosols)
Continued stroke rehabilitation
• Patients with healthcare-associated pneumonia had:
– higher fatality rates (17.8% vs. 6.7%)
– longer mean hospital stay (18.7 days vs. 14.7 days)
– S. aureus and gram-negative bacilli were significantly more
frequent
– The selection of empirical antibiotics include coverage of
methicillin-resistant S. aureus and multidrug-resistant gramnegative rods (such as linezolid or glycopeptides plus an
antipseudomonal β-lactam)
Physician Query
• Dear Dr. Jones. This patient is documented to have
healthcare-associated pneumonia treated with Zosyn,
vancomycin, and tobramycin. If possible, please document
the infectious cause of this patient’s HCAP, given the
antibiotics selected. Thank you for your assistance.
• Answer documented in the progress notes: The patient’s
pneumonia is probably (or appears to be) due to a multiresistant gram-negative rod in the setting of likely aspiration
pneumonia. Same answer repeated three times in the
progress notes.
• Diagnosis documented at the time of discharge:
– Healthcare-associated pneumonia
Question
• Based on the physician’s documentation,
what DRG should this group to?
– MS-DRG 178 – Respiratory Infection &
Inflammations with CC – R.W. 1.4860
• APR-DRG 137 – Major Respiratory Infection
– SOI 2 – R.W. 0.9102
– MS-DRG 194 – Simple Pneumonia & Pleurisy
with CC – R.W. 0.9976
• APR-DRG 139 – Other pneumonia
– SOI 2 – RW 0.6393
• Is further query necessary?
Physician Query
• Dear Dr. Jones. This patient is documented to have
healthcare-associated pneumonia treated with Zosyn,
vancomycin, and tobramycin. If possible, please document
the infectious cause of this patient’s HCAP given the
antibiotics selected. Thank you for your assistance.
• Answer documented in the progress notes: There is evidence
of the patient’s pneumonia being due to a multi-resistant
gram-negative rod in the setting of likely aspiration
pneumonia. Same answer repeated three times in the
progress notes.
• Diagnosis documented at the time of discharge:
– Healthcare-associated pneumonia
Question
• Based on the physician’s documentation,
what DRG should this group to?
– MS-DRG 178 – Respiratory Infection &
Inflammations with CC – R.W. 1.4860
• APR-DRG 137 – Major Respiratory Infection
– SOI 2 – R.W. 0.9102
– MS-DRG 194 – Simple Pneumonia & Pleurisy
with CC – R.W. 0.9976
• APR-DRG 139 – Other pneumonia
– SOI 2 – RW 0.6393
• Is further query necessary?
Documented at the
Time of Discharge
• Discharge note
• Discharge order
• Discharge summary
Coding Clinic Support
• Question: The attending physician for an inpatient admission has
included conditions listed with terms such as "consistent with,"
"compatible with," "indicative of," "suggestive of," and "comparable
with" in the final diagnosis. How should these conditions be coded?
• Answer: Code these conditions as if they were established. These
terms fit the definition of an uncertain diagnosis. According to the
Official Guidelines for Coding and Reporting (Sections II and III), in
short-term, acute, long-term care, and psychiatric hospitals, if the
diagnosis documented at the time of discharge is qualified as
"probable," "suspected," "likely," "questionable," "possible," or "still
to be ruled out," code the condition as if it existed or was
established.
• This advice should not be applied to admitting or interim
diagnoses.
Coding Clinic Support (cont.)
• CC, 3rd Quarter, 2009, page 7.
• Question: Is it appropriate to report codes for diagnoses
recorded as "evidence of cerebral atrophy" and "appears to
be a nasal fracture" when documented on outpatient radiology
reports?
• 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 in
the outpatient setting.
Bottom Line
• Uncertain diagnoses may not be coded
unless documented at the time of discharge
– “Evidence of” = certain
– “Appears to be,” “possible,” “probable,” and other
similar language = uncertain
• If uncertain diagnoses are documented in the
record and there are clinical indicators
supporting that diagnosis, a nonleading query
to clarify or to bring forward the uncertainty to
the discharge note is compliant.
Clinical Scenario #2
• An 80-year-old white female fell out of bed at home and
fractured her hip. En route to the hospital, she develops
substernal chest pain and abnormal EKG changes. While the
troponin was normal initially at the emergency department,
three hours later, it rises above the 99th percentile,
suggesting a non-ST segment elevation MI.
• The patient is admitted, her pain subsides, she is stabilized,
and undergoes a hip pinning on the 8th hospital day.
• Final diagnosis
– Osteoporotic hip fracture POA
– Non ST-segment elevation MI POA
Clinical Scenario #2 (cont.)
• What’s the correct DRG?
– Principal diagnosis – hip fracture
• MS-DRG 480 – Hip and Femur Procedure except Major
Joint w MCC – RW 2.8752
• APR-DRG 309 – HIP/FEM Proc Except Joint
Replacement – Nontraumatic – SOI 3 – RW 2.5005
– Principal diagnosis – acute MI
• MS-DRG 982 – Extensive OR Procedure Unrelated to
Principal Diagnosis with CC – RW 2.8954
• APR-DRG 950 – Extensive Procedure Unrelated to the
Principal Diagnosis – SOI 2 – APR-DRG RW 2.2273
Principal Diagnosis Assignment
ICD-9-CM Official Guidelines
• The circumstances of inpatient admission
always govern the selection of principal
diagnosis.
– The principal diagnosis is defined in the Uniform
Hospital Discharge Data Set (UHDDS) as “that
condition established after study to be chiefly
responsible for occasioning the admission of the
patient to the hospital for care.”
• In determining principal diagnosis, the coding
conventions in the ICD-9-CM, Volumes I and II,
take precedence over the official coding
guidelines.
Principal Diagnosis Assignment
ICD-9-CM Official Guidelines (cont.)
• Two or more diagnoses that equally meet
the definition for principal diagnosis
– In the unusual instance when two or more
diagnoses equally meet the criteria for principal
diagnosis as determined by the circumstances of
admission, diagnostic workup, and/or therapy
provided, and the Alphabetic Index, Tabular List,
or other coding guidelines do not provide
sequencing direction, any one of the diagnoses
may be sequenced first.
Coding Clinic – 3rd Q, 2002, Page 14
Physician Intent for Admission
•
•
Question: A patient is admitted with severe dental caries and periodontal
disease. She has been on Coumadin in the past for clotting of her dialysis
access. This had to be stopped prior to her dental procedure and she
needed to be switched to IV Heparin.
The documentation states that the patient was admitted for
anticoagulant adjustment prior to her surgery. In addition, the history
of present illness specifies, "the primary reason for admission is not
for her teeth extraction but because she has had chronic clotting
problems of her vascular access for dialysis. Every time her Coumadin
is stopped, the patient's access clots." It appears that the dental
extraction would have been carried out as an outpatient if the patient had
not had clotting problems. What should be the principal diagnosis in this
case, the dental condition or V58.61 or V07.8?
Answer: Assign code 521.09, Other dental caries, as the principal
diagnosis. The dental condition required care, and the patient's medications
had to be adjusted in preparation for the dental surgery.
Coding Clinic, 3rd Quarter 2009
Severe Medical Condition Presence
• Question: A patient with an acute ST elevation lateral wall
myocardial infarction (STEMI) was initially seen at Hospital A and
was immediately transferred to Hospital B for an emergency cardiac
catheterization and percutaneous transluminal coronary angioplasty
(PTCA) with stent insertion. What is the appropriate principal
diagnosis for Hospital B?
• Answer: Assign code 410.51, Acute myocardial infarction, of other
lateral wall, initial episode of care, as the principal diagnosis. The
acute STEMI of the lateral wall had not resolved and was still being
treated at Hospital B. Assign code 414.01, Coronary atherosclerosis,
of native coronary artery, as a secondary diagnosis. This advice is
consistent with that previously published in Coding Clinic Fifth Issue
1993, page 14.
Other Guidelines Criteria
Principal Diagnosis Assignment
• Codes for symptoms, signs, and ill-defined conditions
– Codes for symptoms, signs, and ill-defined conditions from
Chapter 16 are not to be used as principal diagnosis when a
related definitive diagnosis has been established.
• Two or more interrelated conditions, each potentially
meeting the definition for principal diagnosis
– When there are two or more interrelated conditions (such as
diseases in the same ICD-9-CM chapter or manifestations
characteristically associated with a certain disease) potentially
meeting the definition of principal diagnosis, either condition may
be sequenced first, unless the circumstances of the admission,
the therapy provided, the Tabular List, or the Alphabetic Index
indicate otherwise.
Other Guidelines Criteria
Principal Diagnosis Assignment (cont.)
• Two or more comparative or contrasting conditions
– In those rare instances when two or more contrasting or
comparative diagnoses are documented as “either/or” (or similar
terminology), they are coded as if the diagnoses were confirmed,
and the diagnoses are sequenced according to the
circumstances of the admission. If no further determination can
be made as to which diagnosis should be principal, either
diagnosis may be sequenced first.
• A symptom(s) followed by contrasting/comparative
diagnoses
– When a symptom(s) is followed by contrasting/comparative
diagnoses, the symptom code is sequenced first. All the
contrasting/comparative diagnoses should be coded as
additional diagnoses.
Other Guidelines Criteria
Principal Diagnosis Assignment (cont.)
• Original treatment plan not carried out
– Sequence as the principal diagnosis the condition that,
after study, occasioned the admission to the hospital, even
though treatment may not have been carried out due to
unforeseen circumstances.
• Complications of surgery and other medical care
– When the admission is for treatment of a complication
resulting from surgery or other medical care, the
complication code is sequenced as the principal diagnosis.
If the complication is classified to the 996–999 series and
the code lacks the necessary specificity in describing the
complication, an additional code for the specific
complication should be assigned.
Other Guidelines Criteria
Principal Diagnosis Assignment (cont.)
• Admission following medical
observation
– When a patient is admitted to an observation
unit for a medical condition, which either
worsens or does not improve, and is
subsequently admitted as an inpatient of the
same hospital for this same medical condition,
the principal diagnosis would be the medical
condition which led to the hospital admission.
Other Guidelines Criteria
Principal Diagnosis Assignment (cont.)
• Admission following postoperative
observation
– When a patient is admitted to an observation unit
to monitor a condition (or complication) that
develops following outpatient surgery, and then is
subsequently admitted as an inpatient of the
same hospital, hospitals should apply the Uniform
Hospital Discharge Data Set (UHDDS) definition
of principal diagnosis as "that condition
established after study to be chiefly responsible
for occasioning the admission of the patient to the
hospital for care."
Other Guidelines Criteria
Principal Diagnosis Assignment (cont.)
• Admission from outpatient surgery
• When a patient receives surgery in the hospital's
outpatient surgery department and is subsequently
admitted for continuing inpatient care at the same
hospital, the following guidelines should be followed in
selecting the principal diagnosis for the inpatient
admission:
– If the reason for the inpatient admission is a complication,
assign the complication as the principal diagnosis.
– If no complication or other condition is documented as the
reason for the inpatient admission, assign the reason for
the outpatient surgery as the principal diagnosis.
– If the reason for the inpatient admission is another
condition unrelated to the surgery, assign the unrelated
condition as the principal diagnosis.
Bottom Line
• Either the hip fracture or the MI can be the
principal diagnosis and still be compliant with
ICD-9-CM
– “The importance of consistent, complete
documentation in the medical record cannot be
overemphasized. Without such documentation
the application of all coding guidelines is a
difficult, if not impossible, task.” – ICD-9-CM
Guidelines
– “(The) determination of the appropriate principal
diagnosis is not always an easy task.” – Coding
Clinic, 3rd Quarter, 2002
Clinical Scenario #3
• A patient with a known history of ASCAD and previous myocardial
infarction is admitted as an inpatient on a Saturday evening for chest
pain to rule out a myocardial infarction. Initial troponin studies and
ECG are negative for acute myocardial ischemia. Due to the lack of
radionuclide, the nuclear stress test is not conducted until Monday,
which was negative.
• Due to the patient being seen promptly, the patient was discharged
at 11:00 a.m. prior to the CDS seeing the patient. No CDS
encounter was generated.
• Final diagnosis on the progress note – noncardiac chest pain,
ASCAD, old MI – which was coded by HIM.
• Discharge medications – aspirin, Protonix.
Clinical Scenario #3 (cont.)
• The medical staff bylaws require a discharge
summary on all inpatient admissions
(outpatient and observation admissions do
not require a discharge summary). The
attending physician, Dr. Johnny Come Lately,
dictated the summary two weeks postdischarge.
• Final diagnosis:
– Noncardiac chest pain probably due to GERD
– ASCAD
– History of old MI
What’s the Appropriate DRG?
• Chest pain
– MS-DRG 313 – Chest Pain – 0.5404
– APR-DRG 198 – Angina Pectoris & Coronary
Atherosclerosis – SOI 1 – 0.4692
• GERD
– MS-DRG 392 – Esophagitis, Gastroenteritis,
& Misc. Digestive Disorder w/o MCC – 0.6921
– APR-DRG – Other Esophageal Disorder –
0.4695
Inquiring Minds Want to Know
• Is it OK to code a record without a
discharge summary?
– Hospitals wish to maintain a Discharge Not
Final Billed average of less than 4 days,
whereas most medical staff bylaws allow a
physician up to 30 days to complete his or her
medical records (including performance of the
discharge summary).
• How can CDI participants help if a coder
has a record without a DC summary?
Coding Without a
Discharge Summary
• ICD-9-CM Official Guidelines for Coding and
Reporting
– A joint effort between the healthcare provider and the
coder is essential to achieve complete and accurate
documentation, code assignment, and reporting of
diagnoses and procedures.
• The Definition of CDCI/CDI
– These guidelines have been developed to assist both the
healthcare provider and the coder in identifying those
diagnoses and procedures that are to be reported.
– The importance of consistent, complete documentation in
the medical record cannot be overemphasized. Without
such documentation accurate coding cannot be achieved.
– The entire record should be reviewed to determine the
specific reason for the encounter and the conditions
treated.
AHIMA Practice Brief – July 2001
Coding Compliance Policy
• Medical records are analyzed and codes selected only with
complete and appropriate documentation by the physician
available. According to coding guidelines, codes are not
assigned without physician documentation. If records are
coded without the discharge summary or final diagnostic
statements available, processes are in place for review after
the summary is added to the record.
• Example: When records are coded without a discharge
summary, they are flagged in the computer system. When the
summaries are added to the record, the record is returned to
the coding professional for review of codes. If there are any
inconsistencies, appropriate steps are taken for review of the
changes.
CDCI’s Role in Support of
the Discharge Summary
• Reminders to providers of
– CMS’ requirement that the record be complete
within 30 days of discharge
– The requirement to code from the COMPLETE
medical record, which includes the discharge
summary
– The allowance to code uncertain diagnoses,
given the discharge summary is a “time of
discharge” document
– The role that the discharge summary plays in the
minds of some retrospective reviewers
Bottom Line
• While records may be coded without a
discharge summary, they should be
flagged so that they may be rereviewed
upon the performance of the discharge
summary.
• CDCI specialists have a role in supporting
the rereview and physician query in the
event of inconsistent, incomplete,
imprecise, or conflicting documentation.
• A patient is admitted for nausea and vomiting. The
patient’s admitting creatinine increases is 1.8 mg/dl.
The CDS who is an RN writes the following:
– The patient was admitted with a creatinine of 1.8
mg/dl with a documented baseline of 1.2 mg/dl. The
chart documents “ARI” and “volume depletion” and
treatment “followed with volume repletion.”
– Please render your clinical opinion if the patient has
acute renal failure based on these indicators by
checking the box below. If you agree, I will update the
problem list and prepare a clarification for your
signature.
(x) Agree ( ) Disagree
Adapted from Source: Payne T. “Improving Clinical Documentation in an
EMR World.” hfm magazine. Published in February 2010.
Clinical Scenario #4
Definitions of Acute Renal Failure
or Acute Kidney Injury
RIFLE
• Risk – ↑ SCr x 150%
– UOP < 0.5 ml/kg x 6 hours
• Injury – ↑ SCr x 200%
– UOP < 0.5 ml/kg x 12 hours
• Failure – ↑ SCr x 300% or
SCr ≥ 4.0 mg/dl with acute ↑
of 0.5 mg/dl
– UOP < 0.5 ml/kg x 24 hours
or anuria for 12 hours
• Loss – Persistent loss of
renal function > 4 weeks
• ESRD – Persistent loss of
renal function > 3 months
AKI Network
Acute Kidney Injury*
• Stage 1
– ↑in SCr ≥ 0.3 mg/dl or ↑
150%–200% from baseline
• Stage 2
– ↑in SCr ≥ 200%–300% from
baseline
• Stage 3
– ↑in SCr ≥ 300% from
baseline or SCr ≥ 4.0 mg/dl
with acute ↑ of 0.5 mg/dl
*Assumes volume repletion
has occurred
2011 IPPS Proposed Rule
• Code (584.9) is being widely used to capture degrees of renal
failure ranging from that which is caused by mild dehydration
with only minor laboratory abnormalities all the way through
severe renal failure that requires dialysis.
• There are no clinical criteria for assigning diagnosis code
584.9 (Acute renal failure, unspecified). The attending
physician must simply document the presence of acute renal
failure for the diagnosis code to be assigned.
• The concern is that the diagnosis code for Acute renal failure,
unspecified (diagnosis code 584.9) is being assigned to
patients with a low clinical severity level.
2011 IPPS Proposed Rule
• Coders are observing the terminology of
“acute renal failure” being applied to
patients who are simply dehydrated.
– These patients do not require renal dialysis
and they do not appear to be severely ill.
• Coders have stated that there appears to
be an increase in the use of the
terminology of acute renal failure for
patients who were previously referred to
as acute renal insufficiency.
Coding Clinic
1st Quarter 2008, p. 3
• The establishment of clinical parameters for
code assignment is beyond the scope of
authority of the Editorial Advisory Board for
Coding Clinic for ICD-9-CM.
• All code assignment is based on provider
documentation.
Indications for Query
2008 AHIMA Practice Brief
• Legibility. This might include an illegible handwritten entry in
the provider’s progress notes, and the reader cannot
determine the provider’s assessment on the date of
discharge.
• Completeness. This might include a report indicating
abnormal test results without notation of the clinical
significance of these results (e.g., an x-ray shows a
compression fracture of lumbar vertebrae in a patient with
osteoporosis and no evidence of injury).
• Clarity. This might include patient diagnosis noted without
statement of a cause or suspected cause (e.g., the patient is
admitted with abdominal pain, fever, and chest pain, and no
underlying cause or suspected cause is documented).
Indications for Query
2008 AHIMA Practice Brief
• Consistency. This might include a disagreement between
two or more treating providers with respect to a diagnosis
(e.g., the patient presents with shortness of breath. The
pulmonologist documents pneumonia as the cause, and the
attending documents congestive heart failure as the cause.).
• Precision. This might include an instance where clinical
reports and clinical condition suggest a more specific
diagnosis than is documented (e.g., congestive heart failure is
documented when an echocardiogram and the patient’s
documented clinical condition on admission suggest acute or
chronic diastolic congestive heart failure).
Is This an Appropriate Circumstance?
• The CDS who is an RN writes the following:
– The patient was admitted with a creatinine of 1.8 mg/dl
with a documented baseline of 1.2 mg/dl. The chart
documents “ARI” and “volume depletion” and treatment
“followed with volume repletion.”
– Please render your clinical opinion if the patient has
acute renal failure based on these indicators by
checking the box below. If you agree, I will update the
problem list and prepare a clarification for your
signature.
(x) Agree ( ) Disagree
Source: Payne T. “Improving Clinical Documentation in an EMR World.” hfm magazine. Published in February 2010.
Inappropriate Use of Query Forms
2001 AHIMA Practice Brief
• Query forms should NOT:
– “Lead" the physician
• Is allowing only the option of acute renal failure “leading” given that
other options of “renal risk” or “renal insufficiency” are not offered?
– Sound presumptive, directing, prodding, probing, or as
though the physician is being led to make an assumption
• What about the option of hypovolemia? Why was that not offered?
– Ask questions that can be responded to in a yes-or-no
fashion
• Is “Agree” or “Disagree” the same as “Yes” or “No”?
– Indicate the financial impact of the response to the query
– Be designed so that all that is required is a physician
signature
Resource: Prophet, Sue. "Developing a Physician Query Process (AHIMA Practice Brief)." Journal of AHIMA 72, No. 9 (2001): 88I-M.
Is This Leading?
Rendered by an RNDS
• The patient was admitted with a creatinine of
1.8 mg/dl with a documented baseline of 1.2
mg/dl. The chart documents “ARI” and
“volume depletion” and treatment “followed
with volume repletion.”
• Please render your clinical opinion if the
patient has acute renal failure based on these
indicators by checking the box below. If you
agree, I will update the problem list and
prepare a clarification for your signature.
(x) Agree ( ) Disagree
Adapted from: Payne T. “Improving Clinical Documentation in an EMR World.”
hfm magazine. Published in February 2010.
MD vs. RN vs. HIM
Queries
• Does a licensed physician or nurse with
clinical knowledge and authority have
authority to “suggest” diagnoses to a treating
or documenting physician if they are not
involved in direct face-to-face patient care?
– For inpatients, coders may not code from
pathology, radiology, or other reports in
circumstances where there is no face-to-face
patient contact
• Bottom line—can they lead?
AHIMA CDI Toolkit
Role of Physician Advisor
• A trained CDI physician advisor on the medical
staff can benefit the hospital by:
– Providing in-services regarding medical conditions for
CDI team and the health information department
– Serving as a liaison between the health information
department and the clinical documentation specialist
and the medical staff to encourage physician
cooperation for thorough and specific documentation
– Providing education to the medical staff regarding
DRGs, the Medicare prospective payment system, or
other payment methodologies
– Assisting the hospital in reviewing and appealing
potential coding and DRG denials
Physician Advisors
Coding Clinic, Sept-Oct, 1984
Question: What support is available to medical records personnel in
those cases where the attending physician and the coder do not
agree?
Answer:
Members of the medical records committee could be asked to serve as
physician advisor to the coding staff.
These physicians could review cases in question and, if the advisor
concurs with the coder, a conference with the attending physician could
be held to solve the documentation problem.
If the hospital employs a physician as medical director, the medical director
could talk with the attending physician after reviewing the medical
record in question.
A third option would be an appeal to a medical staff officer or member who
has good rapport with peers and who understands the necessity for
complete and accurate documentation.
Nursing Practice Act
(California)
•
A. Independent Functions
– Direct and indirect patient care services that insure the safety, comfort, personal hygiene
and protection of patients, and the performance of disease prevention and restorative
measures.
– Performance of skin tests, immunization techniques and withdrawal of human blood from
veins and arteries is included in the practice of nursing.
– Observation of signs and symptoms of illness, reactions to treatment, general behavior, or
general physical condition and determination of whether these exhibit abnormal
characteristics; and based on this determination, the implementation of appropriate
reporting or referral, or the initiation of emergency procedures.
•
B. Dependent Functions
– Direct and indirect patient care services, including, but not limited to, the administration of
medications and therapeutic agents necessary to implement a treatment, disease
prevention, or rehabilitative regimen ordered by and within the scope of licensure of a
physician, dentist, podiatrist or clinical psychologist.
•
C. Interdependent Functions
Implement appropriate standardized procedures or changes in treatment regimen in
accordance with standardized procedures after observing signs and symptoms of illness,
reactions to treatment, general behavior, or general physical condition, and determining that
these exhibit abnormal characteristics.
These activities overlap the practice of medicine and may require adherence to a
standardized procedure when it is the nurse who determines that they are to be undertaken.
Nursing Practice Act
(California) (cont.)
• The Legislature referred to the dynamic quality of the nursing
profession. This means, among other things, that some
functions which today are considered medical practice will
become common nursing practice and no longer require
standardized procedures.
– Examples of medical functions which have evolved into common
nursing functions are the measurement of cardiac output
pressures, and the insertion of PICC lines.
• The means designated to authorize performance of a medical
function by a registered nurse is a standardized procedure
developed through collaboration among registered nurses,
physicians and administrators in the organized health care
system in which it is to be used. Because of this
interdisciplinary collaboration, there is accountability on
several levels for the activities to be performed by the
registered nurse.
Managing the Query Process
2008 AHIMA Practice Brief
• Introduction of new information not previously
documented in the medical record is inappropriate in a
provider query.
– Multiple-choice formats that employ check boxes may be
used as long as all clinically reasonable choices are listed,
regardless of the impact on reimbursement or quality
reporting. Options for “other” and “cannot be determined”
should be included.
• In general, query forms should not be designed to ask
questions about a diagnosis or procedure that can be
responded to in a yes/no fashion.
– The exception is present on admission (POA) queries
when the diagnosis has already been documented.
– In general, it is a much safer practice to ask the provider to
document the diagnosis he or she is agreeing to.
CDI Practice Brief
May 2010
• Quotes from Kathryn DeVault of AHIMA
– “(It) addresses our concerns about leading questions
and introducing information not otherwise contained
in the medical record.”
– “There should not be different rules for different
professionals”
– Suppose a patient had signs and symptoms of
bacterial pneumonia.
• Because of their clinical experience, CDI specialists might
query the physicians to “please document gram negative
pneumonia, if present.”
• The problem with this, DeVault says, is the query doesn’t
give the physicians “any options or ability to use their clinical
judgment. You are leading them to this wording.”
– “Legally, only a provider can diagnose”
Source: AIS Health Business Daily – 3/30/2010
A Duck Is a Duck Is a Duck
No Matter What You Call It
• In its research, the workgroup learned that
instead of using the word “query,” some
organizations present physicians with a
“documentation clarification” or
“documentation alert.”
– But a query by any other name is still a query,
DeVault says, and a leading query is
inappropriate no matter what you call it. “It’s
just semantics,” DeVault says.
Source: AIS Health Business Daily – 3/30/2010
The Baltimore Sun
Bayview settles claims
case for $2.75 million
• “John Hopkins Bayview Medical Center
Inc. has agreed to pay…”
— July 1, 2009
Essentials of Hopkins Case
• Bayview employees were
assigned to work in the
coding department to
assist in clinical
documentation.
• They reviewed charts
relating to inpatient
hospital stays to
determine if there was
any way for the hospital
to increase
reimbursement by
increasing the severity of
the secondary diagnoses
recorded for certain
patients.
Source: Department of Justice
• The employees allegedly
focused on lab test results
which might indicate the
presence of a complicating
secondary diagnosis such
as malnutrition or
respiratory failure, and
advised treating doctors
to include such a
diagnosis in the medical
record, even if the
condition was not actually
diagnosed or treated during
the hospital stay, in violation
of billing rules adopted by
federal health benefit
programs.
Essentials of Hopkins Case (cont.)
• A physician would retrospectively review charts 2–3
times per week.
• If the physician found ONE or more abnormal lab value
(e.g., low platelet count) without any documentation of a
diagnosis or treatment, he would e-mail the attending
physician to tell him or her that if the attending physician
added a diagnosis, the APR-DRG SOI would increase.
• After this communication, he would place a “nonleading”
query on the chart, by which the physician would write
the answer that had been previously negotiated.
• The way the OIG found this was to procure his computer
and review his e-mails.
Bottom Line
• Probably still controversial, but the recent AHIMA
Practice Brief is pretty strong
– A good lawyer knows the law
– A better lawyer knows the judge and the jury
• Critical questions
– Was the person posing the query involved in direct face-toface patient care, prompting a “clinical discussion” directly
related to patient care?
– Are there policies and procedures guiding the “diagnosis
suggestion” process?
– To what extent do industry standards from AHIMA (a
member of the Cooperating Parties) apply to individuals
that are members of that organization?
– Can an organization defend its query process?
Other Circumstances
Postoperative Complications
• Coding Clinic, 3rd Quarter, 2009, page 5
• Question: This patient was admitted and diagnosed with
coronary artery disease and underwent a coronary artery
bypass graft. Postoperatively, the patient was noted to have
hyperglycemia and was followed up by the Endocrine Service.
The physician lists a final diagnosis of postoperative
hyperglycemia. How is postoperative hyperglycemia coded?
• Answer: Assign code 790.29, Other abnormal glucose, for
the postoperative hyperglycemia. Any stress hyperglycemia,
such as postoperative hyperglycemia, should be assigned
code 790.29.
Other Circumstances
Postoperative Complications (cont.)
• It is important to note that not all conditions that occur during
or following surgery are classified as complications.
– First, there must be more than a routinely expected condition or
occurrence.
– In addition, there must be a cause-and-effect relationship
between the care provided and the condition, and an indication
in the documentation that it is a complication.
• The coder cannot make the determination whether something
that occurred during surgery is a complication or an expected
outcome.
– Only a physician can diagnose a condition, and the
physician must explicitly document whether the condition is
a complication. If it is not clearly documented, the coder
should query the physician for clarification.
Bottom Line
• Ascertain that “complications” are indeed
“complications”
– Encourage physicians to not use the word
“postoperative” anything (except perhaps
“postoperative day”) given the need to clarify
these events as complications or not.
– Encourage physicians to state whether
conditions occurring in the postoperative
period are “integral” or not.
• We do need their explicit documentation as to the
presence or absence of complications.
Gratitude
Thank you for allowing me to speak.
James S. Kennedy, M.D., C.C.S.
FTI Healthcare
[email protected]