Health Information Management

Tip: Query to clarify use of the term ’history’

CDI Strategies, July 7, 2011

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Many cases exist in which CDI specialists need to query physicians to clarify the use of the term “history.” Consider the following situation in which a physician admits a patient with pyelonephritis. The past history states right lower lobe lung carcinoma proximal lesion.

The CDI specialist submits the following query:
Dear Dr. X,
A patient was admitted with pyelonephritis. The PHx states, “RLL lung CA – proximal coin lesion.” If possible, please clarify if this has resolved (ex: after complete resection), or if the patient still under treatment and/or still carries this diagnosis. Thank you.
 
This type of query often frustrates both physicians and coders. In clinical speak, past history includes conditions that are current, said Andrew Rothschild, MD, MS, MPH, FAAP, CCDS, director at FTI Consulting in Atlanta.
 
“A patient can have a history of AIDS. It doesn’t mean it went away; it just means that in the history of the patient’s life, he or she contracted the illness,” explained Rothschild, who spoke during a March 18 audio conference “Physician Queries: Apply Industry Guidance to Improve Procedures and Data Tracking.” “Whereas in coding, history means that it happened in the past—these are totally different concepts.”
 
For a case in which the physician has already provided the diagnosis and the coder is just trying to determine whether the diagnosis is relevant at the present time, Rothschild believes that it can be appropriate to ask this type of “A or B” query. He cautioned, though, that the only official AHIMA-accepted use of this format is during a query for POA status. A POA query specifically determines whether a condition is hospital-acquired. This is often confused with querying for principal diagnosis, a completely separate concept, Rothschild noted.
 
“A lot of coders are using the same wordings to query both things,” Rothschild said. “Querying to find out if something was present at the time the patient was admitted is very important and that satisfies [POA] requirements, but it does not necessarily satisfy the definition of a principal diagnosis. A urinary tract infection, for example, may have been [POA], but it may not have been significant enough to have clearly warranted admission. This may require a separate query, if not already sufficiently documented.”
 
Editor’s note: This article first appeared online at www.justcoding.com and is the featured article of the month on the ACDIS homepage. Every month a new article is posted to the ACDIS home page. This article is free and available to all visitors. The past year’s worth of “Featured Articles” are available under the Helpful Resources tab.



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