Help understanding clarifications/queries

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Hello, all! I am a coder, and my wife is a PCP. We work for different health systems in our area. Recently she started to receive what can be compared to a CDI clarification for patients who are scheduled for an outpatient visit (they have not yet been seen). These are coming from people with CPC credentials, and not RNs. Also, these are clearly stated that they will not be part of the medical record. For example, one of them stated that the patient had been diagnosed with diabetes 3 years prior by one of her colleagues, and what does she think about that. Another quoted a CT scan from a year ago that showed calcification and that she should diagnose them with PVD.

I am not an expert on clarifications or queries, but I smell fraud here. I need help to better understand what is happening. I code for a hospital, so my outpatient experience is limited. I am not aware of the process for a coder to scour a patient's chart prior to a visit and then requesting/directing the physician to "pay attention to this problem." Is this practice commonplace? If so, does it have a different name other than a query or clarification?

To me, this is a blatantly fraudulent activity that is intended to direct the physician to boost the severity of the patient's condition. Although I support capturing the patient's complete health picture, if it is not clinically relevant and validated for the current encounter than it is not applicable. The appearance is that they are trying to introduce diagnoses without evidence, and want to hide that process.

I would appreciate any assistance in trying to better understand what is happening. Is this practice normal and compliant? I suspect the answer is a resounding "No!" Are there other resources that you can point me to in order to investigate further?

Thank you all for your help!
 

mitchellde

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I have never heard of such a thing. No it is not appropriate for a coder to scour the medical record to request that a provider look at something, pay attention to something or diagnose anything. A coder is not a physician or clinician and is not educated in the clinical significance of test results and prior histories. The provider should go to the medical coding supervisor and ask what is going on and challenge the validity of these requests. In my Opinion.
a coder may request clarification... for instance I recently had a chart indicating the patient is 8 weeks pregnant however the exam indicate an absence of the uterus and ovaries due to a recent hysterectomy. You see that as a coder I need clarification on this note! and A coder is allowed to query for additional information such as left limb or right limb. A coder is only allowed to look at information documented in a specific encounter note and code from that note. I think this is actually written in the Federal register, I remember several years back I performed a web query and happened on an except I think it was in the federal register on coders and coding responsibilities. Unfortunately that piece of information has slipped from me but I would be willing to bet you can locate it again.
 
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thomas7331

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Your situation raises more questions than it answers and I hesitate to try to answer or draw any conclusions from this. I agree the best approach would be to discuss this with a supervisor or perhaps the organization's compliance officer. These sound like unusual requests to me too, especially from a coder and happening before the provider has seen the patient, but then again, a lot of unusual things are happening in healthcare these days. I would not jump to the conclusion that this is fraudulent activity without knowing more about who is collecting this information and how it is being used.

It's hard to understand from the limited information you've given what is really happening, i.e. who is making the requests, what, where and how this information is going to be used and what the expectations are for your provider. It would not be fraudulent unless the information is used to misrepresent services in order to obtain improper payment, but this could potentially be additional concerns about the proper use of the patient's records. It's hard to imagine that in this day and age a healthcare organization would undertake something like this without first vetting it with their compliance officers, but you never know. Best to take it through the proper channels and inquire about it with someone who knows the details and can answer your concerns - you have legitimate questions and any responsible organization should be willing and able to address them.
 
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Hcc coder auditor

It sounds like you are talking about a Prospective Chart Review for Chronic Conditions related to Risk Adjustment.

Going by the vague example of CT scan, it sounds like, there is clinical documentation to support the diagnosis. If the provider does not agree, they certainly do not need to address the issue.

Many times qualifying chronic conditions get buried in a chart or don't transfer from physician to physician.

I understand that for inpatient you submit the acute conditions (ex:Acute Kidney Injury) we do outpatient chronic conditions.

Compliance, correct coding and physician documentation are all required aspects of Prospective HCC Reviews.

Agreed that to suggest a code without clinical support would indeed be fraudulent.

Sincerely,

Nadine A. Guiliano, CPC, CRC
Kathy Fitzpatrick, CPC
 

mfana

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MFana MD CPC CPMA CPCO

I have to say that if one of mike coders or CDIs come to me or any of our colleague with a condition we would welcome and review it. Being a physician 18 years and with coding credentials for 5 years, I know for a fact, if you code something that is there, you are more likely to treat it and educate the patient. As far as the CT with atherosclerosis (calcification) it implies that that physician-patient already should have a discussion about lifestyle prevention and cholesterol as well as blood pressure. Humility goes a long way. Eventually she can decide as the doctor if she wants to put it there, but I would welcome it.
 
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