Q: How have you handled situations when specialty physicians and hospitalists do not agree with diagnoses impacting core measures?
A: It becomes difficult because the clinical definitions of some disease processes are a little bit tricky or fuzzy. In specific scenarios such as acute myocardial infarction (AMI) and congestive heart failure (CHF), we’ve brought together a team of coding, quality, case management, and the physician groups that are involved, and come up with clinical definitions. We tried to select the most widely accepted clinical definition of CHF, because we don’t want to pick the most obscure definition that’s out there and narrow the field down to the point where we’re going to look odd when you compare us to other hospitals.
You want to pick the clinical definition that’s the most widely accepted clinical definition for this condition; CHF as one example and AMI is another perfect one. We try to sit down with the physicians involved, and our hospitalists, and come together on the same page about what the definition of a STEMI is and how we are going to document that in the chart. That cut down a lot of the back and forth that we’ve had along the way. The coders got stuck in the middle of it. Coders don’t feel comfortable going up to a physician and saying, “Okay, Doctor Jones documented this as a STEMI, but you're saying it’s not. You're saying it’s not even an AMI.”
That situation puts the coders and CDI staff in a very difficult position. We’re not the physician who’s ultimately responsible for the diagnosis of the patient, but we’re trying to dig through all the information.
By having an agreement about what that clinical picture is for a patient, a clinical definition for a diagnosis really sets the groundwork so that you don’t have all those conflicts back and forth in the chart.
It’s not a perfect world. We still have some cases that have to be clarified, but the nice thing is when you don’t have it happening all the time. You can follow the coding guideline about the attending physician being ultimately responsible for the diagnoses of the patient and you can go back to that attending physician. At our facility, sometimes that’s a challenge, because the attending may not be the one who knows the most about that clinical condition. But it’s the way the rules are written, and so by following the rules and setting those clinical definitions, you can really make an impact on not having so much back and forth in the chart.
Editor’s note: Heather Taillon, RHIA, manager of corporate coding support services at Franciscan Alliance in Greenwood, Indiana, answered this question.
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