Health Information Management

Q&A: Offering physicians options does not necessarily pose compliance risk

CDI Strategies, October 28, 2010

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 Q:Recently, a consultant suggested that if we asked the physician to clarify systolic/diastolic on a query form for congestive heart failure (CHF) it might be construed as leading the physician if there had been no previous mention of systolic/diastolic anywhere else in the chart. We never place a query unless the physician states CHF in chart, and if the physician does not specify the type we query for it. If we include the phrases systolic/diastolic on the query form would that be considered introducing new information?

A: “Topic-specific query templates can increase the CDI specialist’s daily productivity as such queries can be quickly communicated to the physicians,” writes Fran Jurcak, RN, MSN, CCDS, manager in the CDI practice of Wellspring Partners, in Chicago, in The CCDS Study Guide.
However…“clinical indicators of a more specific or detailed diagnosis should be present before posing a query to a physician…Use diagnostic testing, including an echocardiogram to determine ventricle functionality and ejection fraction of the left ventricle [as evidence from these tests] provides the most information to assist in diagnosing systolic or diastolic dysfunction, but only physician documentation of the diagnosis [can be used] for final coding of the condition,” Jurcak writes.
Furthermore, AHIMA’s Guidance for Clinical Documentation Improvement Programscites several query examples which offers physicians choices of additional specificity which may have not been previously included in the chart, says Lynne Spryszak RN, CCDS, CPC-A, CDI education director for HCPro, Inc., in Marblehead, MA.
The Guidance states:
“Typical situations addressed by a query include presenting clinical indicators of an undocumented condition, requesting further specificity or the degree of severity of a documented condition, clarifying a potential cause and effect relationship, and addressing present on admission issues.”
The Guidance offers a sample query regarding COPD exacerbation which includes several response options with language not explicitly stated in the medical record including:
  • Acute respiratory insufficiency
  • Acute respiratory failure
  • Acute on chronic respiratory failure
  • Some other cause of respiratory distress
  • Undetermined
  • Not applicable
Such options allow the physician to determine his or her own clinical judgment, including the option to disagree with the submission of the query entirely by choosing “not applicable.”

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