Q&A: Multiple query options can confuse syncope clarifications

April 29, 2010

Q: Our CDI specialists tend to ask questions that provide the physician with multiple options to choose from. It is not uncommon to have a query with multiple answers checked by the physician.

For example, in answer to the question “What is the cause of the patient’s syncope?” options include cardiac arrhythmia, anemia, and other. In response, the physician then chooses “all options given” and also writes in “dementia.”

In this case, would it be appropriate to choose any of the options as the principal diagnosis based on the following ICD-9-CM guideline?

Two or more diagnoses that equally meet the definition for principal diagnosis: In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.

Or would it be more appropriate to code the syncope first followed by the chosen diagnoses based on the following ICD-9-CM guideline?

A symptom(s) followed by contrasting/comparative diagnoses: When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as additional diagnoses.

A: Tamara Hicks: Syncope is a symptom in this example so it should be sequenced first. Now, if it were not a symptom code then the first guidelines listed above would apply.

Heather Taillon: In this situation, however, the physician is indicating that all of these things are causing the syncope. If he or she were saying “I do not know which one of these it is, it could be any of them causing the syncope,” [then the first guideline would apply] but if the physician is saying all of these things, all of these diagnosis, contributed to the symptom, then in that situation it does go back to the two-or-more interrelated conditions guideline and you have to figure out treatment-wise what was the focus of care or what was the reason for the patient’s admission to the hospital.

Gail Marini: This might be also be a question dealing with the physician query process. Linking the final diagnosis to the presenting symptom diagnosis of syncope needs to be supported by medication changes, treatment plans, and medical intervention.

Checking off several diagnosis offered on the query could be a physician education issue and not a coding guideline issue. The physician needs to understand they cannot simply check off every option just to be done with the query.

Glenn Krauss: The first thing I would do is validate that the doctor wasn’t in a hurry and checked off a bunch of things on the query form just to get on to the next patient.

Pam Lovell: These sorts of examples are good reasons why check off queries are like a closed digit question in that you don’t necessarily get the best answer, you just get an answer. If you reworded the question as: “What was the syncope treatment directed toward?” The physician will tell you. He knows why he’s chosen one modality over another.

James Kennedy: Of any diagnosis in CDI, syncope is among the more problematic ones. From the three options listed we have no etiologies that can be discerned, so we’re left with the syncope.

Editor’s note: ACDIS Advisory Board members answered this question during the February 18, 2010 Quarterly Conference Call. The next quarterly call will be held on Thursday, May 27 from 3-4 p.m. EST. Dial in information will be e-mailed to ACDIS members prior to the call.

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