Coders, Queries, and CDI
The CDIS isolates common problems to strengthen the overall patient record.
by Nancy Reading, RN, BS, CPC, CPC-P, CPC-I
Clinical documentation is integral to every inpatient or outpatient encounter to provide continuity of care and a legal record of a patient’s health status. Reimbursement, compliance, and specificity are likewise tied to documentation-driven coding. The role of the clinical documentation improvement specialist (CDIS) is to review clinical documentation to verify it’s complete, legible, accurate, and timely. There are common problems with clinical documentation, and it’s important to know how the CDIS works to improve potential shortcomings.
Fill Common Gaps in Documentation
Culling through documentation in the patient record to show support for diagnosis codes is a complex process. Provider documentation may fall short in several common ways. By isolating these common problems, the CDIS often is able to help providers significantly strengthen the overall patient record.
For example, when a patient is admitted to the inpatient environment, the provider’s orders may include insulin or levothyroxine without mention of either diabetes or hypothyroid disease in the admission history and physical or the daily progress notes. Sometimes, these diseases are mentioned only in the past medical history (PMH), and not as part of the assessment and plan. These are chronic disease processes that will need continuous drug therapy and monitoring, regardless of the reason for the current inpatient stay.
To ensure these conditions are properly recognized, the provider should document their presence and ongoing treatment/maintenance in the assessment and plan (medical decision-making) portion of the note. You, in turn, should hone selection of reportable diagnosis codes to this area of the provider note. All too often, the conditions listed in the PMH are no longer a factor in patient care, nor are they identified as improving, stable, or worsening.
Look Out for Auditor Targets
Here’s another common scenario: You’ll see documentation of debridement of an ulcer down to the fascia. But did that include the fascia? How was the debridement done? Recovery audit contractors (RACs) have recouped millions of dollars for “excisional debridements” that weren’t really excisional, or that weren’t fully documented to support the coding reported. Trimming up skin fragments around the wound edges is not considered invasive enough per CMS or in RAC audits to count as excisional debridement.
Documentation must be clear as to the size and depth of the wound. The tools used to remove any devitalized or necrotic tissues should be specifically listed. Auditors look to see if the provider used scissors or a scalpel and whether they removed just the fragments around the wound edges or excised non-viable tissues down to and including “X level” of healthy tissue. In CPT® terms, think of the skin debridement codes in the 10000 section as excisional, and the debridement codes found in the 90000 section as non-excisional.
For more information on correct documentation and reporting of excisional debridement, see the February 2011 Medicare Quarterly Provider Compliance Newsletter.
Be Solution Oriented
What should you do if you notice a shortcoming or inconsistency in provider documentation? For example, recently I encountered a chart with daily progress notes citing renal insufficiency on one day and acute renal failure on the next, followed again by a note citing renal insufficiency. Renal insufficiency codes to 593.9 Unspecified disorder of kidney and ureter, and acute renal failure codes to 584.9 Acute kidney failure, unspecified. Providers frequently use these terms interchangeably, without knowledge of or regard for the impact on coding and the bottom line.
Query the Provider
In such situations, your job is to query the provider. This can be done verbally or in writing, but not in an email or with a sticky note in the chart. The provider should never be forced, coerced, or lead into documenting a diagnosis that is not appropriate or supported by clinical indicators.
Clinical parameters should be set by the providers for a specific diagnosis. When those parameters are discovered without proper documentation of a problem that clearly is being treated (that is, you find clinical parameters and orders for treatment, but no documentation of the problem), you should cite the clinical parameters and ask the provider to determine or clarify the diagnosis requiring treatment.
A 57-year-old male is recovering from bilateral total knee arthroplasty surgery. He had an estimated blood loss (EBL) of 300 cc on the left knee and 250 cc on the right knee. His initial hemoglobin and hematocrit (H&H) are 16.5 g/dl and 44 percent (considered within normal limits for the institution), respectively. After surgery the patient has a low blood pressure, and the morning H&H on the following day has dropped to 10g/dl and 28 percent, respectively. The provider orders a transfusion of one unit of packed red blood cells.
Tip: Other clinical indicators to look for are postural hypotension, amount of EBL in surgery greater than normal for the procedure, and/or large output from post-operative drains.
In this case, there are clinical indicators of a greater than 10-point drop in hematocrit, low blood pressure, and a total EBL of 550. The problem also is treated with an infusion. The key here is the treatment. Most patients lose some blood in surgery, and there is a wide range of how well patients tolerate this and how it shows up in the morning blood work.
Don’t Cry Wolf
If you query a provider every time the H&H drop a few points, you’ll look like the coder who cried wolf and become a huge burden to the provider. The provider should not be queried here, unless the patient is symptomatic and transfused. At times, during surgery the patient will receive a large quantity of intravenous fluids and the anemia is dilutional, not due to blood loss. Sometimes, it takes a day to two for all the fluids to level out.
The moral of the story is to set clinical parameters with help from your providers to direct you as to when it’s appropriate to query the provider. Determine the following:
- Is the query in writing or verbal?
- How is it tracked?
- Will the institution where the provider is practicing make the query part of the permanent medical record?
Now is the time to make a plan, educate providers and yourself, and put the plan into action. If you take the time now to address and train on the problem areas specific to your practice, you’ll be in a better position to work with ICD-10-CM.
Diagnoses Needing the Most Work
Conditions most often documented poorly, or not at all, are:
- Congestive heart failure
- Sepsis, severe sepsis, systemic inflammatory response syndrome
- Acute and/or chronic renal failure
- Acute blood loss anemia
- Pressure ulcers and debridement
- Acute respiratory failure
How CDI Affects Inpatient Stays
In the early 1970s, Yale University developed diagnosis-related groups (DRGs), which were later implemented by the Centers for Medicare & Medicaid Services (CMS). These groups are reported to describe all types of patient care in an acute care hospital. The DRG system allows only one DRG assignment per patient stay; payment includes all services that occur between hospital admission and discharge.
DRGs are used to drive reimbursement under the Inpatient Prospective Payment System for inpatient stays. In 2007, the government tiered the DRG system to account for patient acuity associated with complications and co-morbidities. Medicare Severity DRGs (MS-DRGs) were adopted and became effective with discharges occurring on or after October 1, 2007.
MS-DRGs represent a three-tiered system: Tier 1 has no complication or co-morbidity, tier 2 has a complication/comorbidity (CC), and tier 3 has a major complication/comorbidity (MCC). MCCs and CCs speak to secondary diagnoses of either an extreme level of severity or a secondary diagnosis representing a mild to moderate level of severity, respectively. Some secondary diagnoses neither significantly affect the patient’s primary diagnosis nor add to the severity of illness or resource consumption. These secondary diagnoses should still be coded, even if they do not lend to assignment of an MS-DRG and/or additional reimbursement.
Note that the MCC or CC diagnosis cannot be coded unless it’s accurately and specifically documented. A great example of this is congestive heart failure (CHF). ICD-9-CM and ICD-10-CM guidelines require that the provider document CHF as acute, chronic, or acute on chronic, and systolic or diastolic, and right sided or left sided. The accurate and appropriate documentation of this diagnosis can mean tens of thousands of dollars to a hospital’s bottom line.
Nancy Reading, RN, BS, CPC, CPC-P, CPC-I, is a nurse with a Bachelor of Science in Biology/Chemistry and 25 years of coding experience. She has worked the gamut from a large university practice with more than 1,000 providers to Medicaid. Reading is a past employee of AAPC, and she is a member of the Salt Lake South Valley, Utah, local chapter.
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