Health Information Management

Include clinical details when posing queries about congestive heart failure

JustCoding News: Inpatient, July 7, 2010

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Querying when physician documentation seems sparse may be tempting. However, coders and clinical documentation improvement (CDI) specialists should only initiate a query when clinical evidence in the medical record supports doing so.

Queries should always include clinical details as well because they help provide a context for physicians to understand the purpose of the queries, counsels Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS, a consultant in Orlando, FL.

The American Health Information Management Association query practice brief, Managing an Effective Query Process, also encourages coders to query using clinical information gleaned from the record. The practice brief states:

It is recommended that queries be written with precise language, identifying clinical indications from the health record and asking the provider to make a clinical interpretation of these facts based on his or her professional judgment of the case.

Congestive heart failure (CHF) is one example of a condition for which coders and CDI specialists should understand clinical indicators before querying physicians, says Lynne Spryszak, RN, CCDS, CPC-A, a CDI educator at HCPro, Inc., in Marblehead, MA.

Be on the lookout for these specific clinical clues to provide clinical support for a CHF query, says Spryszak:

  • An echocardiogram that shows an ejection fraction (EF) of less than 50%, which is indicative of systolic heart failure, or an EF of greater than 50%, which generally indicates diastolic heart failure.
  • An echocardiogram that shows ventricular hypertrophy, an indicator of chronic heart failure. Look for evidence of decreasing EF and usage of home heart failure medications.
  • Increasing doses of diuretics (e.g., physician order of “Lasix 40 IVP now” or “Increase Lasix to BID”). These orders may indicate treatment of an acute or acute-on-chronic episode of heart failure.
  • Physician orders that reference cardiology consults, an echocardiogram, or a heart failure standing order set.
  • Other indicators, such as a CHF teaching form, core measures documentation form, or a nursing assessment that includes jugular venous distension, moist breath sounds, shortness of breath, or labored breathing.

In general, consider the following tips when using clinical criteria to support a query:

  • Include the date and time of the test along with the normal (or abnormal) findings.
  • Ensure that the clinical information is logical and that it supports the question. Don’t query when the data do not support the definition of a certain condition, says Brown.
  • Identify the location, date, and provider that pertain to documentation that needs clarification or validation.
  • Reference appropriate clinical definitions or resources (e.g., RIFLE criteria [i.e., risk, injury, failure, loss, and end-stage kidney disease] for renal failure).
  • Reference pertinent clinical findings, such as lab values, medications, or treatment descriptions of the patient’s condition, pertinent medications, pertinent abnormal test results, or normal test results that contradict documentation of an abnormality.

Editor’s note: Content in this article was originally presented during HCPro’s March 24 audio conference “Physician Queries Workshop: Tools and Techniques for Compliant, Effective Clarification.” During the presentation, Spryszak and Brown discussed querying tips for several other problematic conditions, including renal failure, sepsis, and encephalopathy.

This article was originally published in the June issue of Briefings on Coding Compliance Strategies. E-mail your questions to Contributing Editor Lisa Eramo, CPC, at leramo@hotmail.com.



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