Q&A: Bringing Forward Documentation from Previous Encounters

Q: Although I understand that a coder cannot code from a previous encounter’s documentation, can the CDI specialist bring information to the physician’s attention such as laboratory results in order to obtain a baseline for renal failure/chronic kidney disease (CKD)?

A: It is true coders cannot assign codes based on documentation from a previous encounter. Code assignment must be based solely on the present episode of care.

And yet, as you suggest in your question, a historical perspective is often needed for the physician to determine the most accurate diagnosis such as in determining the stage of CKD as well as determining the type of heart failure (diastolic, systolic, or combined).

Let’s look at both cases. To accurately stage CKD, the physician must have access to the trending estimated glomerular filtration rate (eGFR). Typically, the CDI specialist would query the provider to determine the stage of CKD since advanced stages affect severity of illness/risk of mortality and may constitute a CC if captured as a secondary diagnosis.

Many CDI programs include documentation of the renal disease trending information as part of the clinical indicators of the query when asking for the stage. This is a practice that I always felt comfortable with; we were not applying a code based on documentation from a previous record, we were pulling clinical indicators to support a query. The provision of the trending information saved the physician the time required to access previous data and provided the information needed to determine an accurate diagnosis for the patient. The provision of the trending information usually assisted in motivating the physician to answer the query.

However in order to include this information, the provider first must supply the underlying diagnosis. For example, the provider must state the patient has chronic congestive heart failure, before the CDI specialist could place a query using an ECHO report from a previous encounter. If the provider does not state chronic CHF, you would not want to include that previous information since it may not be relevant to this particular episode of care and could be seen as an attempt to lead the physician to document a condition not currently being treated.

It may be best to lean on the side of caution.

Editor’s Note: CDI Boot Camp Instructor Laurie Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, answered this question on the ACDIS Blog; see also the related August 28 CDI Strategies Q&A. Contact her at lprescott@hcpro.com.

For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview.