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Strategy: Put the "clinical" back in clinical documentation review

CDI Strategies, October 16, 2008

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Too many CDI specialists focus strictly on DRG assignment when reviewing medical records when they should be engaging the clinical half of their brain, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDIS, senior coding and chargemaster consultant with QHR in Brentwood, TN. His suggestion? Think like a physician when reviewing patient charts.

"Documentation specialists should be using their mindset of clinical medicine to identify the hidden agenda in the medical record, and not get bogged down in the DRG," he says.

Krauss recalls a recent experience with a brand-new CDI specialist who had significant past experience as a critical care nurse. Although she knew very little about coding, she used her clinical experience to formulate an effective query, resulting in a firm diagnosis by the physician where previously he had only documented symptoms.

The case was as follows: A patient was admitted to the intensive care unit and had been hospitalized for three days without a definitive or provisional diagnosis. The progress notes contained only symptoms, including altered mental status and unresponsiveness.

The CDI specialist set to work on the case by reviewing the ambulance sheet, ED notes, orders, diagnostic tests, and the progress notes.

The ambulance sheet revealed a critical clue that the patient could not be roused. In his history and physical, the physician documented that the patient's family found him on the floor at his home. The hospital progress notes indicated that the patient was unresponsive for two days into the hospitalization. The ED physician documented "altered mental status" as a provisional diagnosis, secondary to a cerebrovascular accident (CVA) and drug intoxication.

The physician later ordered a CT scan that confirmed a definite CVA.

The CDI specialist queried the physician, but not for a specific diagnosis in order to arrive at a predefined DRG. Instead, she asked for his thoughts on the case regarding the patient's altered mental status and loss of consciousness.

The trauma nurse, realizing that most non-hemorrhagic stroke victims remain conscious, queried for clarification of the physician's "clinical thoughts as to why the patient remained unresponsive for two-plus days," Krauss says. The physician confirmed a diagnosis of a coma due to the non-hemorrhagic CVA and the drug intoxication.

"Most people only looking for the CC or MCC would not have recognized the coma," Krauss says. "It's about tying your clinical expertise into your record review."

Krauss says the case is also a good example of how to review a record, as the CDI specialist was able to uncover key clues about the case by reviewing the ambulance sheet and ED notes.

"Don't go to the progress notes first; it's like looking at the answers to a crossword puzzle before you look at the question," Krauss says. To help stay abreast of the latest trends in medicine, Krauss recommends the following resources:

• The New England Journal of Medicine. This costs $99 for an annual subscription but is published weekly and has a fully searchable archive back to 1991. "It's the best $99 you ever spent," he says.
• Mayo Clinic Proceedings, which includes many free articles, available at the Mayo Clinic Web site: www.mayoclinicproceedings.com
• www.sepsis.com, which includes clinical indicators and educational resources and tools.
• American Medical News, www.ama-assn.org, which allows CDI specialists to keep up on business and other financial issues affecting physicians, including compensation and public profile data
• National Pressure Ulcer Advisory Panel, www.npuap.org, which contains clinical definitions and other resources related to education on the different types of pressure ulcers
• AHA News Now daily e-mail, and twice per month AHA News Magazine, which are available here: www.ahanews.com. These publications contain pertinent hospital-related news helpful in keeping up to date on the general business of healthcare from a financial and healthcare happenings standpoint, Krauss says.

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