Q&A: Workflows for querying, malnutrition, and pathology
Q: I am interested in others’ approaches to certain risk adjustment diagnoses like malnutrition and pathology results. At our facility, the CDI department writes all the queries, so the coder will send a request to query to the CDI specialist if the attending physician has not documented the registered dietician (RD) findings or pathology findings in their notes. Does anyone else have a process, workflow, or vendor to try to catch these and other diagnoses necessary for chart completion? We have a vendor that prioritizes our charts based on the diagnostic evidence—they are currently investigating how to use this to get diagnoses brought to our attention if a query is needed.
Response #1: We built disappearing tips into provider templates for malnutrition. So, when the RD makes a diagnosis of a certain kind of malnutrition, the provider can just pull it into their note. The CDI team also receives an inbasket message at the same time just in case the provider misses it. We also worked with our vendor to build out a malnutrition workflow, so if it gets to the coder and the documentation is not updated, the coder can send a query.
Response #2: We have put a large focus on the CDI specialist finalizing the chart after the coder has completed coding to make sure there are no errors/differences in codes, and to make sure that the pathology reports and discharge summary have been evaluated for clarification opportunities. We have found that even when we worked hard to cover cases in real time, the final coding was often not optimal, or there was conflict between previous documentation and the discharge summary. This was a huge shift in our workflow. Since we started this process, our department has made a greater impact both financially and qualitatively.
Response #3: Our organization utilizes a prioritization program. There is a setting to “flag” charts with RDs documenting malnutrition; we are getting it to work for pathology results even after discharge as well. But these requests take time. We also have SmartPhrases built into our provider templates to assist them in documenting these crucial diagnoses.
Our CDI liaison team has also created tip sheets that have been presented to providers and are available on our SharePoint page at any time for any staff to read/use as a resource. We also have systemwide clinical definitions for some diagnoses and links to these diagnoses.
That being said, no CDI tool is perfect, and we still miss some malnutrition and pathology queries. In cases like this, the coders send them to the staff that have already reviewed the account, or we have a core list of eight CDI staff available to review a coder query request if the account has never been reviewed. We also have outside vendors that monitor CDI and coding patterns.
Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council. For the purposes of this article, all Council member answers have been deidentified.