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Strategy: Look to official ICD-9-CM guidelines for examples of compliant queries

CDI Strategies, January 10, 2008

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There are certain diagnoses for which the ICD-9-CM Official Guidelines for Coding and Reporting require coders to query when necessary. The guidelines state that if the documentation is not clear as to whether acute respiratory failure and another condition are equally responsible for occasioning the admission, for example, clinical documentation specialists and/or coders should query the provider.

"Let's say sepsis is present on admission [POA], and it is accompanied by acute organ dysfunction, such as respiratory failure," said Alison Nicklas, manager for the Healthcare Advisory Consulting Practice for PricewaterhouseCoopers in Albany, NY, during a recent HCPro audioconference. "It's necessary to determine if the respiratory failure is the result of sepsis or not. This is an instance where clarification is needed."

Some other examples in which clinical documentation specialists should consider querying the physician include:

• Transplant complications--Are these complications of the transplant, adverse effects of the drugs, or another condition? The ICD-9-CM Official Guidelines state that if the documentation is unclear as to whether the patient has a complication of the transplant, it is necessary to query the provider.
• Fractures--What is the order of severity? According to the ICD-9-CM Official Guidelines, CDI staff/coders should ask the provider to list the fracture diagnoses in the order of severity.
• Abnormal lab results--Does the physician feel there is any clinical significance for that particular abnormality? Per the ICD-9-CM Official Guidelines, if the findings are outside the normal range, and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added. Note that the American Hospital Association's Coding Clinic, Vol. 24, No. 4, fourth quarter 2007, also references this information.

(Source: Briefings on Coding Compliance Strategies).

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