Q&A: Querying for the link between diabetes and diabetic complications

Q: I am looking for help posing queries regarding the specific link between diabetes and conditions typically considered diabetic complications. Should we always query the physician regarding the link between the presenting symptom and the diabetes?

A: A cause-and-effect relationship between diagnoses may not be assumed and coded unless documented as such by the attending physician; therefore the CDI specialist may need to query the physician to ascertain such documentation defining the connection between diagnoses.

A query form may state that fact as an introductory statement, then summarize the patient’s clinical indications according to information from his or her medical record, and prompt the physician to indicate a potential cause-and-effect relationship if clinically appropriate. Here is sample language you might adapt to your facility’s needs:

A cause-and-effect relationship between diagnoses may not be assumed and coded unless documented as such by the attending physician. The patient presented with ___________ (“neuropathy”, “diabetes”, and “CKD” as documented in the H/P.). Please document the cause-and-effect relationship, if any, between these conditions and the patient’s diabetes using one (or more) of the following examples as clinically appropriate:

• Diabetic foot ulcer
• Diabetic CKD
• Diabetic neuropathy
• Diabetes related: foot ulcer/neuropathy/CKD neuropathy/CKD/foot ulcer due to diabetes
• Other __________________
• Undetermined

This is one of those main educational messages (cause and effect) that you’ll want to communicate prior to query dissemination to the medical staff. However, the more consistently you ask this type of question, the sooner providers will get used to documenting that relationship appropriately the first time.   In my opinion, repetition and consistency achieves results.

In general, you can always ask:  “Is there a cause-effect relationship between the following conditions ______________ and ________________?  If so, please document this relationship in the progress notes and discharge summary.” Then give appropriate options similar to the ones I listed above.

Some other examples where cause-effect queries are necessary include:

• Hypertension and heart disease
• Diabetes and any associated complications (neuro, vascular (PVD), eye, kidney, etc.)
• Sepsis and localized infection
• Complications of malignancies (obstruction due to, respiratory condition due to, etc.)

If you base your query policies using AHIMA guidance documents you should be in good shape, but always have any query templates approved by your compliance officer and/or legal counsel before you start using your queries.

My opinion is that there’s nothing inappropriate in telling the providers why you’re asking the question.  In this case, you’re giving them the coding rules, which they did not previously know.

Editor’s Note: Lynne Spryszak, RN, CPC-A, CDI Education Director for HCPro Inc., Danvers, MA, answered this question. At the time of this article's original release, Spryszak was an independent HIM consultant based in Roselle, IL. Her areas of expertise include clinical documentation and coding compliance, quality improvement, physician education, leadership and program development.