HomeTown Health HCCS Hospital Consortium Project: Track 2 Clinical Documentation Program: E ssentials and Took Kits Jenan Custer RHIT, CCS, CPC, CDIP AHIMA Approved ICD-10-CM/PCS Trainer Director of Coding Healthcare Coding and Consulting Services (HCCS) Melissa Edenburn, MS, RHIA, CCS AHIMA Approved ICD-10-CM/PCS Trainer Senior Inpatient Auditor and Trainer Healthcare 2017 Coding Healthcare and Coding Consulting & Consulting Services (HCCS) 1 Learning Outcomes By the end of this session, attendees should be able to: Define how Anatomy, Physiology, and Pharmacology are pertinent to CDI Identify what a query is, and when it is needed Recognize Clinical indicators, and how to build a compliant query Defining the query process (concurrent, retrospective, and verbal) Have a working knowledge of Query templates Recognize how to structure a compliant query Identify best practices and Policies and procedures surrounding compliant queries Learning Outcome Standard: This program is based on compliance guidelines set forth by entities like, but not limited to: AHIMA, ACDIS, CMS, The Joint Commission, and Local FI/MACS. 2 Disclosure of Proprietary Interest HCCS does not have any proprietary interest in any product, instrument, device, service, or material discussed during this learning event. The education offered by ICAHN in this program is compensated by the HRSA Small Hospital Improvement Program (SHIP) grant, Iowa FY17-18, Contract #5888SH01. 3 1
Anatomy, Physiology, and Pharmacology Understanding from the coding perspective Due to the clinical nature of ICD-10-CM, a strong understanding or experience in anatomy and physiology is required PCS root operations Clinicians were not required in ICD9 to document to the level of specificity ICD 10 requires The clinician is not required to use PCS terms CDI and Coders must interpret the documentation in order to apply procedure codes correctly Defining Clinical Indicators Clinical indicators are the supporting elements for a particular diagnosis Laboratory or diagnostic test results and consist of many parts: Imaging studies Treatments-medications, interventions, infusions, services Patient assessments and plans of care (by all caregivers) Signs and Symptoms Observations Objective data -Vital signs, BP, Temperature, Heart rate What is a physician query? A query is defined as 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 Effective Management of Coding Services Lou Ann Schraffenberger AHIMAdefinition- A routine communication and education tool used to advocate complete and complaint documentation 2
What CMS Says about Queries Per DHHS (Department of Health & Human Services) Office of Clinical Standards and Quality - PRO 2001-13 Use of the physician query form is permissible to the extent it provides clarification and is consistent with other medical record documentation. Query forms should be: Clearly and concisely written Contain precise language Present the facts and identify why the clarification is needed Present the scenario When a Query is needed: Documentation that is Conflicting- Lobar Pnaon H&P / Pna, unspecified on DC Ambiguous K+, +/- Illegibility- see example Incomplete- abnormal lab and txbut no dx Lack of clarity- symptoms but no dx Inconsistency- Sepsis here, Urosepsis there When a Query is needed: AHIMA/ACDIS 2013 practice recommendations The desired outcome from a query is an update of the health record to better reflect a practitioners intent and clinical thought processes, documented in a manner that supports accurate code assignment Guidelines for Achieving a Compliant Query Practice HCProApril 2013 3
When a Query is needed: Think like a coder The circumstances of inpatient admission always govern the selection of principal diagnosis. 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. Coding Guidelines Section II. When a Query is needed: Coding Clinic 3Q 2008 "Any clinical information published in Coding Clinic,is provided as background material to aid the coder's understanding of disease processes. The information is intended to provide the coder with "clues" to identify possible gaps in documentation where additional physician query may be necessary. It is not intended to replace the need for specific physician documentation to substantiate code assignment." Coders cannot assume When a Query is needed: NOT about financial impact- It s about good GREAT documentation Is the diagnosis considered reportable? UHDDS defines this as a condition requiring: Clinical Evaluation Therapeutic treatment Diagnostic procedures Extended length of stay (LOS) or Increased nursing care and/or monitoring Does the physician state the diagnosis is present within the patient encounter? Coding Clinic Reference: 3Q 2007 pgs13-14 Coding of Chronic Conditions-clarification 4
When a Query is needed: Concurrent queries initiated real time, during the course of the patient encounter or hospitalization at the time the documentation is naturally done. Retrospective queries are effective in cases where additional information is available in the health record, in short stays where concurrent review was not completed, or whenever a concurrent query process is not feasible. Post-bill queries are initiated after the claim is submitted or remittance advice is paid; generally occur as a result of an audit or other internal monitor. AHIMA Practice Brief 2008 Types of Queries One is not better than the other Open-ended- answers are completely open to provider Multiple Choice-some clinical direction, but offer other or unknown Yes/No- cause and effect or conflicting dx from a consultant Verbal- interaction with provider, requires follow through Query templates Types of Queries- examples Open-ended Patient was admitted from ED with symptoms of fever and malaise.. Patient started on IV pressors for hypotension and IV fluids. Initial vitals BP 87/56, HR 122, WBC s 22,000, lactic acid 4.3. Based on your clinical judgement, please provide a diagnosis that represents the above symptoms and clinical indicators. Patient was admitted with UTI. Urine culture obtained in ED showed presence of E Coli and patient was started on appropriate antibiotics. Please clarify the relationship between the UTI and urine culture. 5
Types of Queries- examples Multiple Choice Documentation within the health record reflects Congestive Heart Failure. In order to accurately code this case to reflect the appropriate severity of illness, we ask that you specify the type as outlined below: 1) Acuity 2) Type Acute Systolic Chronic Diastolic Acute on Chronic Combined Systolic and Diastolic Unable to Determine Unable to Determine Types of Queries- examples Yes / No H&P indicates patient has chronic kidney disease. Consulting Nephrologist indicates patient has stage 4 CKD. Do you agree with nephrologist diagnosis ofckdstage 4? Yes No Types of Queries- examples Verbal 6
Types of Queries- examples Query Templates Standardized form Limits risk of a leading question Do not fit every circumstance Need to be unique to each case Need involvement from all parties to ensure buy in and compliancy Steps to Compliant Queries AHIMA s 2016 Guidelines for Achieving a Compliant Query Practice continues to state: A leading query is one that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or procedure. The justification (i.e., inclusion of relevant clinical indicators) for the query is more important than the query format. Steps to Compliant Queries Query MUST include: Clinical indicators needed to support your query Signs and symptoms- include duration Lab or diagnostic findings Consultant findings Treatments and medications administered Written in compliant fashion Non-leading Signed, dated and responses made part of the permanent medical record Queries are not meant to question a physicians judgment 7
Steps to Compliant Queries AHIMA does not specifically define what a leading query is, but they do address the definition in reference to an example of a leading query by stating: the provider is not given any option other than the specific diagnosis requested. In other words: The question gives the desired answer AHIMA. Practice Brief, "Managing an Effective Query Process"Journal of AHIMA79, no.10 (October 2008): 83-88. Steps to Compliant Queries To support why a query was initiated, all queries must be accompanied by the relevant clinical indicator(s) that show why a more complete or accurate diagnosis or procedure is requested. Clinical indicators should be derived from the specific medical record under review and the unique episode of care. Clinical indicators supporting the query may include elements from the entire medical record, such as diagnostic findings and provider impressions. The AHIMA/ACDIS Query Practice Brief of 2013 Clinical Indicators What are Clinical Indicators? Clinical indicators offer support within the record for the diagnoses applied to the patient. They can consist of: Laboratory or diagnostic test results Imaging studies Treatments-medications, interventions, infusions, services Patient s response to treatment Patient assessments and plans of care (by all caregivers) Symptoms Observations Objective data-vital signs, height/weight etc. 8
Steps to Compliant Queries Hospitals must adapt policies and procedures for the query process: Initiator of the Query- CDI vs Coding Physician reviewer for certain DRG s Time frame for answering Placement of query response and retention policy Outline indicators and definitions for controversial diagnoses Coding Clinic use- 3Q 2008 Common Clinical Indicators Coding Clinic 3Q 2008 "Any clinical information published in Coding Clinic,is provided as background material to aid the coder's understanding of disease processes. The information is intended to provide the coder with "clues" to identify possible gaps in documentation where additional physician query may be necessary. It is not intended to replace the need for specific physician documentation to substantiate code assignment." Programs should develop their own set of clinical criteria Common clinical indicators- SEPSIS Common clinical indicators: Fever (> 101 F/ >38.3 C) or hypothermia (<96.8 F/ < 36.0 C) WBC > 12,000 or <4,000 or >10% Bands Tachycardia, Tachypnea Elevated procalcitonin, Elevated C-reactive protein Altered mental status Evidence of acute organ failure Common treatment includes: IV antibiotics, IV Fluids-aggressive hydration Oxygen Vasopressors Monitoring of vital signs, urine output, etc. surviving Sepsis Campaign: International Guide-lines for management of severe sepsis and septic shock, 2012. Critical Care Medicine 2013;41:580-637. 9
Symptoms: Shortness of breath, tachypnea, diaphoresis, cyanosis Dyspnea, wheezing Accessory muscle use, intercostal muscle retractions Inability to talk w/o gasping for air (Professional MERCK manual) Diagnostics: ABG may show Hypoxemia po2 < 60 mmhg or SpO2 < 91% on room air Hypercapnia pco2 >50 mmhg with ph < 7.35 Treatment: Supplemental oxygen Treatment aimed at underlying condition BiPap, CPAP, Mechanical Vent are not required to diagnose Acute Respiratory Failure (ARF) Put the knowledge to use: Is this a good Query? Dear Doctor Smith: The patient has elevated WBCs, tachycardia, and is given an IV antibiotic for Pseudomonas cultured from the blood. Are you treating for sepsis? Yes No Put the knowledge to use: Is this a good Query? Dear Dr. Smith, On your admission H&P, bilateral lower extremity edema is noted, however, there are no other clinical indicators to support malnutrition. Do you agree that the patient s bilateral lower extremity edema is diagnostic of malnutrition? Please document your response in the health record or below. Yes No Other Clinically Undetermined 10
Put the knowledge to use: Is this a good Query? Dear Dr. Smith, Your patient was admitted with an acute gastrointestinal bleed. After admission his hemoglobin drops from 12 g/dlto 7.5 g/dland two units of packed red blood cells are transfused. Anemia is noted in the final discharge statement. Query: In this patient admitted with a gastrointestinal bleed and who underwent a blood transfusion after a drop in the hemoglobin from 12 g/dl on admission to 7.5 g /dl, can your documentation of anemia be further specified as an acute blood loss anemia? Please document your response in the health record or below accompanied by clinical substantiation. Yes No Other Clinically Undetermined Learning Outcomes Now that this session is complete, attendees should be able to: Define how Anatomy, Physiology, and Pharmacology are pertinent to CDI Identify what a query is, and when it is needed Recognize Clinical indicators, and how to build a compliant query Defining the query process (concurrent, retrospective, and verbal) Have a working knowledge of Query templates Recognize how to structure a compliant query Identify best practices and Policies and procedures surrounding compliant queries 32 References Handouts: Inpatient Physician queries policy Unanswered Query Policy References: Merck Manual- Professional Edition Surviving Sepsis Campaign: International Guide-lines for management of severe sepsis and septic shock, 2012 The AHIMA/ACDIS Query Practice Brief of 2013 AHIMA. Practice Brief, "Managing an Effective Query Process"Journal of AHIMA79, no.10 (October 2008): 83-88. Effective Management of Coding Services Lou Ann Schraffenberger 11
Value Quality THANK YOU FOR YOUR TIME WE WELCOME ALL QUESTIONS 239.443.3900 info@hccscoding.com www.hccscoding.com 34 12