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Clinical Parameters to Guide Provider Documentation Queries

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  • August 2, 2016
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Clinical Parameters to Guide Provider Documentation Queries

When medical documentation is unclear or incomplete, the coder’s 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. With the introduction of electronic medical records (EMR), best practice is for queries to be in writing via messaging systems imbedded in many of the EMR programs. 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. Clinical best practices can be determined internally by a physician group, in concert with the hospital governing body. Clinical guidelines are defined as a systemically developed statement of clinical parameters used to assist with provider and patient decisions with regards as to how best care for a specific condition. When those parameters are identified in the medical record without the expected documentation of the condition they define, or the condition under treatment (e.g., the coder finds clinical parameters and orders for treatment, but no documentation of the problem), the coder should cite the clinical parameters found and ask the provider to determine or clarify the diagnosis that requires the treatment.

Example: A 57-yr-old male is recovering from bilateral total knee arthroplasty (TKA) surgery. He had an EBL of 300 cc on the left knee and 250 cc on the right knee. His initial Hemoglobin and Hematocrit are 16.5 g/dl and 44 percent (considered WNL for the institution), respectively. After surgery the patientis hypotensive (90/40), and the H&H on the following day has dropped to 8 g/dl and 28 percent, respectively. The provider orders a transfusion of one unit of PRBC’s. Additional clinical indicators to look for are postural hypotension, amount of estimated blood loss in Surgery (EBL) 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 HCT, low blood pressure, and a total EBL of 550. Also, the problem is treated with an infusion. The key here is the treatment. Most patients will loose blood in surgery, and there is a defined range of what is acceptable, based on the surgery performed. Auditors will look for these parameters to ensure hospital coders are not upcoding to obtain a higher DRG. The American Society of Hematology generally advocates transfusion is appropriate for a Hgb of less than 7 g/dl in stable patients and less than 8 g/dl in patients who have cardiovascular symptoms, are unresponsive to fluid resuscitation, or have congestive heart failure.
A coder who queries a provider every time the Hemoglobin and Hematocrit drop a few points will become a burden. The provider should not be queried, in our example, unless the patient is symptomatic and he or she is transfused. Sometimes, during surgery, the patient will receive a large quantity of IV fluids and the anemia is dilutional, not due to blood loss.
To repeat: Set clinical parameters, with help from your providers, which direct the coder as to when it is appropriate to query the provider.
Determine how to initiate a query, the policy for provider response, how a query is tracked, and what is necessary to consider the query resolved. There are usually coder/provider metrics tracked regarding query outcome, provider agreement rates, and financial impact to the facility. It is important to determine whether the institution will make the query a part of the permanent medical record. Now is the time to make a plan, educate the provider/coders, and put the plan into action.

Nancy Reading

About Has 2 Posts

Nancy Reading, RN, BS, CPC, CPC-P, CPC-I, has 42 years in healthcare as a nurse and coder. She has worked in the professional, hospital outpatient, and hospital inpatient settings. Her career includes having her own consulting business, working for a large university medical center, Medicaid, and as a Medicare specialist for the country’s largest private third-party payer. She is a two-time past local chapter president, National Advisory Board member, and previously worked for AAPC as VP of education.

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