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Tip: Query when treatment/monitoring of patient supports the question

CDI Strategies, January 24, 2008

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Clinical documentation improvement (CDI) specialists shouldn't be afraid to query, says Heather Taillon, RHIA, manager of coding compliance at St. Francis Hospital in Beech Grove, IN. After all, in the 2008 Inpatient Prospective Payment System final rule CMS stated the following:

We highly encourage physicians and hospitals to work together to use the most specific codes that describe their patient's conditions. Such an effort will not only result in more accurate payment by Medicare, but will provide better information on the incidence of this disease in the Medicare patient population.

But CDI specialists need to query compliantly. For example, they should query on concurrent review of documentation for clinical "results/picture" that are not documented in the chart. Also, they should look to determine whether the clinical picture and treatment/monitoring of the patient supports the question they are asking, Taillon notes. Following is a clinical example that demonstrates this point:

A patient has a hemogloblin of 12 g/dl on admission prior to surgery. Postoperatively, the patient's hemoglobin drops to 8 g/dl, and the physician does not document postoperative blood loss anemia in the chart. If the physician provides no further treatment, do not query in this case. "Even though you have a clinical picture, no treatment was provided," Taillon says.

However, if in the same example, the physician orders a transfusion or reassesses the surgical site with further testing, a query is warranted.

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