Health Information Management

Tip: Provide clinical updates, resources to physicians as part of your CDI duties

CDI Strategies, June 25, 2009

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Along with their daily duties of chart review, CDI specialists should consider themselves as purveyors of clinical updates to physicians, providing articles and clinical references to back up their queries and requests for clarification, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, an independent consultant located in Madison, WI.
By showing physicians the latest information on transient ischemic attack (TIA) and its relationship to strokes, as referenced in the June 1 Journal Watch Emergency Medicine, you not only improve documentation habits, you also strengthen your own reputation as someone with a good clinical understanding of diagnoses and thereby potentially improve your query response rates.
For example, if a patient comes to the emergency room with symptoms of a TIA (e.g., focal neurological deficit of 5–15 minutes, difficulty with speaking) that resolves, but the physician documents a score of seven or higher on his or her Age, Blood pressure, Clinical features, Duration, Diabetes (ABCD2) score, the patient has a 33% chance of evolving to a stroke.
This information may not prevent a Recovery Audit Contractor denial for a one-day inpatient stay, but because the physician adhered to quantifiable and qualifiable measures of risk stratification built upon clinical standards of medicine, this documentation will help support a successful appeal for a one-day stay medical necessity denial.
“The physician might rule out stroke in a day or two, but if we have some relationship to the ABCD2 score documented in the record, and a clear picture of risk stratification and a need to evaluate the patient as described above, we can see because of the high risk score the patient belonged in the house as an inpatient,” he says.
Length of stay has no bearing on the appropriateness of the stay, reminds Krauss.
Some case managers or utilization review professionals automatically assign patients with specific diagnoses (e.g., syncope, TIA, chest pain, etc.) as observation status. But Krauss notes that Medicare guidelines specify that patient status is based upon the ordering physician’s intention at the time of admission, not upon the services that are actually provided.
“The key element is the expectation of a need for a stay approximating 24 hours,” Krauss says. “The physician should document risk factor stratification and clear inference of expectation of a 24-hour stay for further patient workup in the medical record.”
The ABCD2 score and other similar tools allow physicians to document their thought processes more efficiently and effectively in the record. “Documentation improvement is not just about querying for specific diagnoses, but solidifying the documentation in the record to support the diagnosis that the physician is writing,” Krauss says. “This allows you to capture severity and not just buzzwords.”
Provide links to the information in a physician newsletter or a simple e-mail. Explain to physicians that by documenting stroke instead of TIA (when appropriate), and also the patient’s risk factors (for example, female older than age 72 with a history of stroke, hypertension and diabetes), they are simultaneously establishing medical necessity to support the evaluation/management level for his or her professional billing.
“Medical decision-making, clinical impression, and the nature of the presenting problem all tied together and solidified through capture of physician’s clinical thought processes in the form of medical record documentation is what drives a physician’s E/M level,” Krauss says.
For more information on TIAs and the latest definition by the American Heart Association, Krauss recommends the following article from the AHA Journal:

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