By Donald A. Butler, RN
New “variations” on reasons to query physicians was one topic mentioned several times during the recent ACDIS Conference in San Diego. In my opinion, it is also one worth thinking through and addressing head on.
"Providers should be queried whenever there is conflicting, ambiguous, or incomplete information in the health record regarding any significant reportable condition or procedure. Healthcare entities could consider a policy in which queries may be appropriate when documentation in the patient’s record fails to meet one of the following five criteria:
Questionable diagnoses and documentation consistency may well be increasingly added to a CDI specialist’s reason to query list, as ACDIS Advisory Board member James S. Kennedy, MD, CCS, Managing Director of FTI Healthcare in Brentwood, TN, mentioned during his portion of “The Physician Advisor’s Role in CDI: A Collaborative approach for success” pre-conference event on May 8.
Kennedy suggested that a new element of "unreliable diagnosis,” i.e., one that is not clinically supported; and a new variation of the concept of “consistency,” i.e., how frequently a given diagnosis is mentioned within the record, are increasingly required as government and private payer auditors deny payment for these reasons.
Kennedy presented the acronym M.U.S.I.C. to use as a model for CDI record reviews. This model may be useful as it drills through layers of due to, caused by, and demonstrated by, queries CDI specialists typically submit to physicians. It stands for:
- Manifestation (i.e., sepsis, heart failure, chest pain, angina)
- Underlying pathology: (i.e., urinary tract infection, alcoholic cardiomyopathy, GERD, coronary atherosclerosis)
- Severity or specificity: (i.e., accelerated hypertension, severe sepsis, uncontrolled diabetes)
- Instigating or precipitating cause: (i.e., indwelling Foley catheter, nonsteroidal anti-inflammatory drug use, poisoning)
- Complications or consequences: (i.e., septic shock, diabetic neuropathy)
Additionally, Kennedy emphasized the importance of partnering with medical staff to develop standard definitions for target diagnoses and conditions, something frequently discussed on CDI Talk
as well. This would help to point toward specific items that may be missing in the documentation to support the diagnosis.
Editor’s Note: Butler is a Clinical Documentation Improvement Manager at Vidant Medical Center in Greenville, NC, and a 2011 recipient of the CDI Professional of the Year award.