Journal excerpt: Top diagnoses leading to clinical validation

The top diagnoses leading to clinical validation queries tend to follow a pattern, and it’s likely one that will come as no surprise to even newer CDI professionals. For Elizabeth Aguirre, MD, CCDS, Jera Van Damme, BSN, RN, CCDS, CCS, and Cathy Testerman, CCS, CCDS, sepsis takes a top slot.

“Part of the issue is when a condition might look like sepsis and then tests come back negative, but the diagnosis is never removed from the chart or clearly documented as being ruled out,” says Aguirre, who is the CDI program physician lead at Baylor Scott and White Medical Center in Temple, Texas. “The other part is the lack of consensus regarding the use of Sepsis 2 versus Sepsis 3 diagnostic criteria across the medical community.”

Just as at Van Damme’s organization, Baylor Scott and White also has a team responsible for developing systemwide guidelines for sepsis diagnoses.

“Developing clinical definitions for these problem diagnoses has helped immensely,” says Van Damme, the senior clinical documentation educator at Essentia Health in Duluth, Minnesota. Her facility created the educator position to help physicians with these clinical definitions and validation queries.

“We’ll send a query and the physician sees the topic and thinks they’ve already documented for it, so they’ll ignore,” she says. “We’ve found the best thing to do is to get on the front end of this and educate them.”

In addition to sepsis, pediatric malnutrition, acute respiratory failure, and acute renal failure can also cause consternation.

“Any time there is a lack of consensus across the medical community, these diagnoses lead to clinical validation queries,” says Aguirre. “You have to give physicians more solid guidance with these issues. We’ve found it important to educate regarding the rationale for endorsing specific sepsis criteria and explain quality programs related to the diagnosis and what accurate documentation means for our quality reporting.”

“Education is the most important factor,” echoes Testerman, who is the manager of coding and CDI at Greater Baltimore (Maryland) Medical Center. “We made a pocket guide for physicians, our educator does quarterly education on these topics during staff meetings, then we also do chart reviews and meet one-on-one with physicians as needed.”

Editor’s note: This article is an excerpt from the March/April CDI Journal. Click here to read the full edition, which focuses on query practices.