By Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI
Coding accuracy is paramount for accurate reporting of patient acuity, risk of morbidity/mortality and readmission, and true quality of care outcomes. It is also vital for obtaining third-party payer reimbursement that matches hospital resource consumption.
Hospital clinical documentation improvement (CDI) program initiatives and heightened coder awareness of the need to query when clinically warranted can be an asset or liability. Clinical queries to affect documentation improvement have become so ingrained in the overall medical record documentation process that the American Health Information Management Association (AHIMA) in conjunction with the Association for Clinical Documentation Improvement Specialists (ACDIS) crafted Guidelines for Achieving a Compliant Query Process, which was published in the Journal of AHIMA in February.
Coding queries can be an asset in a wide variety of clinical situations as pointed out in the AHIMA/ACDIS guidelines. According to the guidelines, coders should consider querying when the health record documentation:
- Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
- Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis
- Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure
- Provides a diagnosis without underlying clinical validation
- Is unclear for present on admission indicator assignment
When crafting a compliant clinical query, coders need to incorporate clinical indicators, such as abnormal lab values, radiology report results, nuclear medicine results, etc.
The AHIMA/ACDIS guidelines go on to state that multiple choice query formats should include clinically significant and reasonable options as supported by clinical indicators in the health record, recognizing that one reasonable option may be available. A yes/no query format is not permitted when only clinical indicators of a condition are present, but the physician has not documented the condition/diagnosis in the record. In short, a new diagnosis cannot be introduced with a yes/no query format. However, yes/no queries, per the AHIMA/ACDIS guidelines are appropriate in the following circumstances:
- Substantiating or further specifying a diagnosis that is already present in the health record (i.e., findings in pathology, radiology, and other diagnostic reports) with interpretation by a physician
- Establishing a cause and effect relationship between documented conditions such as manifestation/etiology, complications, and conditions/diagnostic findings (e.g., hypertension and congestive heart failure, diabetes mellitus and chronic kidney disease)
- Resolving conflicting documentation from multiple practitioners
Healthcare organizations can benefit from judicious use of a clinical query process that adheres to the AHIMA/ ACDIS guidelines for achieving compliant queries. An effective CDI initiative consisting of CDI specialists concurrently reviewing medical records on the floor, complemented by coding staff appropriately querying physicians prior to finalizing coding to ensure accurate and compliant ICD-9-CM code assignment is essential for assuring data integrity.
Adhering to the AHIMA/ACDIS guidelines for compliant queries in and of itself does not necessarily improve the integrity of hospital reported data. On the contrary, a carefully constructed clinical query may contribute to inaccuracies in diagnoses reporting, patient clinical acuity, and heightened risk of outside reviewer scrutiny and financial recoupment for MS-DRG assignment.
The following case study will clearly illustrate this very point of a clinical query resulting in potential recoupment of hospital reimbursement for assigned and billed MS-DRG.
- Seventy-six-year-old female patient presented to the ED with three days of worsening temperature with chief complaint of not feeling well and increased frequency of urination and symptoms of back pain and dysuria. Patient complained of not having an appetite, not drinking much, and being thirsty and generally weak. Temperature in the ED was 101° F, white count of 12, eight bands, and blood pressure of 90/60 with serials of 100/80 and 130/90 readings while in the ED. IV antibiotics with orders for fluid were initiated in the ED. Provisional diagnoses by the ED physician were pyelonephritis, dehydration, and hypotension. The attending physician evaluated the patient on the floor, conducted his History and Physical, and assessment and plan were acute pyelonephritis with dehydration, hypotension, and concern for early sepsis.
- Plan was for IV antibiotics, continued fluids with encouragement of eating and drinking, monitoring of vital signs and lab values, and hopeful discharge back to home with order for physical therapy as patient was just released from the hospital with a stroke about a month ago and is still exhibiting signs of ataxia and difficulty in ambulation.
- Patient responded well to therapy and was discharged from the hospital on day two with discharge orders for five more days of PO antibiotics and follow up in her primary care physician the Monday of the following week.
The discharge summary outlined as final diagnoses acute pyelonephritis with hypotension, dehydration, and ataxia. The ataxia improved somewhat with physical therapy with plans for outpatient physical therapy. The coder, recognizing the appropriateness of a clinical query in the face of incomplete documentation within the record, queried the physician for thoughts on sepsis after study and treatment in the hospital. The physician responded to the query with documentation of early sepsis with septic shock. The coder assigned sepsis as the principal diagnosis with septic shock as a major comorbid condition, arriving at an MS-DRG assignment of 871 (septicemia or severe sepsis without MV 96+ hrs with MCC). The clinical query appeared to be appropriate and compliant for clarification purposes and all is well that ends well.
The commercial third-party payer reimbursed the hospital for MS-DRG 871 and six months later sent a Notice of DRG change related to clinical validation. An outside organization contracted by the third-party payer selected this case for review likely based upon the patient’s short stay of two days with discharge home billed with MS-DRG 871 with an average length of stay of 5.2 days. The intent to “recode” this record to acute pyelonephritis with deletion of sepsis and septic shock will result in DRG assignment 690 (kidney and urinary tract infections without MCC) with a much lower relative weight (more than50% less) and an average length of stay of 3.2 days.
Coder conundrum
This type of clinical scenario frequently surfaces on a regular basis, exposing the coder to a coding conundrum whereby clinical findings and facts of the case do not support a documented diagnosis. The joint AHIMA/ACDIS guidelines provide for a query to the physician for clarification. As stated in the guidelines:
When a practitioner documents a diagnosis that does not appear to be supported by the clinical indicators in the health record, it is currently advised that a query be generated to address the conflict or that the conflict be addressed through the facility’s escalation policy.
In the above case, the patient’s clinical indicators as documented do not necessarily lend themselves to sepsis and septic shock. The principles of management of septic shock were not evident in the chart, as outlined in a Medscape article titled Septic Shock:
- Early recognition
- Early and adequate antibiotic therapy
- Source control
- Early hemodynamic resuscitation and continued support
- Corticosteroids (refractory vasopressor-dependent shock)
- Drotrecogin alpha (severely ill if APACHE [Acute Physiology And Chronic Health Evaluation] II score >25)
- Tight glycemic control
- Proper ventilator management with low tidal volume in patients with acute respiratory distress syndrome (ARDS)
Keep in mind that this patient was discharged to home late on day two of hospitalization. The fact the patient experienced an episode of hypotension in the face of acute pyelonephritis is not necessarily indicative of septic shock.
Septic shock is diagnosed if the patient experiences refractory hypotension (low blood pressure that does not respond to treatment). This signifies that intravenous fluid administration alone is insufficient to maintain a patient's blood pressure from becoming hypotensive. Hence, the likely reason for the third-party payer to select this chart for review, an easy and lucrative target for reimbursement and profitability for the insurance company.
So what is the coder to do in this situation? The joint organization guidelines strongly recommend the hospital coding department develop a reasonable, workable, and formal resolution policy to address the very issue of clinical documentation of diagnoses not supported by the clinical facts of the case.
Clinical validation of submitted inpatient hospitalizations is assuming a greater presence by all payers including Medicare in the interest of healthcare spending cost containment. It is also becoming an integral component of third-party payers’ business models.
Instead of relying on a time-tested strategy of querying the physician for additional information that can be considered nothing more than a knee-jerk reaction, the hospital should develop, plan, implement, and fine tune a formal escalation policy addressing conflicting or incomplete medical record documentation. Some facilities find material benefit in using CDI specialists to address and resolve documentation inconsistencies and clarifications in the face of clinical documentation incongruent with the clinical facts of the case.
To this end, the CDI has the opportunity to educate and heighten physician awareness of the necessity for clear, concise, and consistent clinical documentation throughout the chart, closely approximating the physician’s clinical judgment, medical decision-making, and thought processes. CDIs can weave correlation with the clinical facts of the case into the fabric of the physician education process.
Clinical queries can be an asset or liability, depending on the direction and process taken by the coding department. Third -party payers are increasingly conducting clinical validation as a key part of their claims processing operations. As a result, facilities should strongly consider developing, implementing, and adhering to well thought out query policy to maintain the integrity of the hospital’s overall revenue cycle program and its associated fiscal health.
Editor’s note: Krauss is a senior manager with Accretive Health. Reach him at gkrauss@accretivehealth.com