Q&A: Prior information and validation in query efforts
Q: Our facility asks CDI specialists to look-back six months in previous records for clinical evidence (such as an ECHO report or ejection fraction) for evidence of heart failure diagnosis. I am concerned about the compliance of this practice as I was taught that we could only take information from the patient’s current care encounter.
A: Your question goes to the heart of two very pressing CDI concerns. The first is that of clinical validation—how far and deep do you need to look for clinical indicators to support the query and, what is the role of CDI in ensuring that supportive information related to the diagnosis gets captured in the medical record. The ACDIS white paper “Clinical validation and the role of the CDI professional,” addresses several important aspects related to these types of concerns and can help you and your program to develop policies and procedures around best practices. (Note that AHIMA also recently published a paper on clinical validation. AHIMA members can read it here.)
The second item you mentioned is addressed in the new Guidelines for Achieving a Compliant Query Practice—2019 update regarding use of prior information. The paper was the topic of ACDIS’ Quarterly Conference Call Thursday, February 14.
In excerpt, it cites AHA ICD-10-CM/PCS Coding Clinic, Third Quarter 2013, pp. 27-28, “Assigning codes using prior encounters” which states:
“When reporting recurring conditions and the recurring condition is still valid for the outpatient encounter or inpatient admission, the recurring condition should be documented in the medical record with each encounter/admission. However, if the condition is not documented in the current health record, it would be inappropriate to go back to previous encounters to retrieve a diagnosis without physician confirmation.”
The practice brief points out Coding Clinic speaks to code assignment, not query construction. A query may be initiated to clinically validate a diagnosis leveraging information from a prior health record to support the need for a query. This can be particularly helpful when clarifying for specificity or when clarifying for the presence of a condition which is clinically pertinent to the present encounter supporting accuracy of care provided across the healthcare continuum.
The ACDIS/AHIMA brief states that prior encounter information may be referenced in queries for clinical clarification and/or validation if it is clinically pertinent to the present encounter. However, it is inappropriate to “mine” previous encounter documentation to generate queries not related to the current encounter.
Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CRC, CDI education specialist for HCPro in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps, click here.