Querying for SOI, ROM

March 2, 2015

CDI Blog - Volume 8, Issue 7

Coders and CDI specialists can use a three-step approach to query for SOI and ROM, Baine says. The first step is to review the clinical indicators.

"You're determining what indicators are significant for a complex diagnosis," says Sara Baine, MSN-Ed, CCDS, a CDI consultant for MedPartners HIM in St. Louis, who spoke during the webinar "Why Do My Sick Patients Appear So Healthy? Capturing Accurate SOI/ROM Documentation to Ensure Quality of Care."

Don't pull in clinical indicators that are related to something else.

"You can't lump two diagnoses into one query. It would be great if we could do that because physicians get very angry if you have to place three or four queries," Baine says.

In addition, some facilities limit the number of queries a CDI specialist or coder can send at one time.

Step two is to look at the treatment. What kind of treatment is applicable for the diagnosis? "Don't put treatments in the query that are not essential to the diagnosis you're looking for," Baine says. Doing so could steer the physician in a different direction and be considered leading.

Step three is to determine the appropriate diagnoses for each query. The majority of queries for SOI and ROM will be potential diagnoses, Baine says. "You can't introduce new evidence, but if you can give sufficient information about what the clinical indicators are, the treatment plan that was offered, and diagnoses, if you're able to do that within your query guidelines for your facility, then you should be able to get the information you need from the physician."

In many cases, CDI specialists need to speak to the physician face to face because the physician may not understand what the CDI specialist is looking for. The CDI specialist may need to give extra background information from the chart as well.

"You can't just give the one you were looking for and say, 'This is what I need,' " Baine says. "You need to give the physician a listing of appropriate diagnoses."

Applying the query process
Let's look at some examples of how coders and CDI specialists would follow this three-step process for the ED patient who died on day three of her stay? Coders and CDI specialists could send four separate queries for this case.

The first query involves the principal diagnosis.

Step 1, clinical indicators: 84-year-old patient with:

Urinary tract infection
Temperature 104 degrees
Unresponsive
Blood pressure 76/50
Heart rate 105
Saturation 87% on non-rebreather
White blood cell 42,000

Step 2, treatment:

3 liters IV fluid
Levophed drip
Intubated/ventilator
Vancomycin IV

Step 3, potential diagnoses:

Based on the information provided, please document if you are treating any of the following:

Septic shock
Shock unrelated to trauma
Unable to determine
Other (please specify)

The second query focuses on the respiratory problems.

Step 1, clinical indicators:

Patient's respiration at 8 breaths per minute and oxygen saturation at 87% on non-rebreather. In addition, the patient is unresponsive.

Step 2, treatment:

Non-rebreather progressed to intubation/ventilator management. Patient had assist control vent with rate of 12, oxygen level to 90%.

Step 3, potential diagnoses:

Based on the information provided, please document if you are treating any of the following:

Acute respiratory failure
Acute respiratory insufficiency
Other diagnosis (please specify)
Unable to determine

Some facilities may have templates for coders and CDI specialists to use when choosing diagnoses. "Make sure that you audit that and delete any diagnosis that is not pertinent or that doesn't match your indicators and treatment," says Rhonda Peppers, RN, BS, CCDS, a CDI consultant for MedPartners HIM who also spoke on the webinar.

The third query opportunity involves the patient's unconsciousness.

Step 1, clinical indicators:

Unresponsive to painful stimuli
Pupils 4 mm and nonreactive

Step 2, treatments:

Neuro checks q1h

Step 3, potential diagnoses:

Based on the above information, please document if you are treating any of the following:

Coma
Obtunded
Other diagnosis (please specify)
Unable to determine

Coma and obtunded are the only pieces of information appropriate for these clinical indicators and treatment, Baine says. "You want to give the physician sufficient information to make a valid choice so it's not a leading query."

The fourth potential query involves renal function.

Step 1, clinical indicators:

86 year old patient with chronic renal insufficiency
BUN 62, creatinine 3.4
Documented baseline creatinine of 1.0
Unresponsive
Blood pressure 76/50

Step 2, treatments:

3 liters IV fluid
Levophed drip

Step 3, potential diagnoses:

Based on the information provided, please document if you are treating any of the following:

Acute renal failure with acute tubular necrosis
Acute renal failure without acute tubular necrosis
Other diagnosis
Unable to determine

"We're looking for acute renal failure with acute tubular necrosis, and one of the reasons that we were going for the tubular necrosis is because of the blood pressure being low, 76/50, and renal failure with your 3.4 creatinine and with a baseline of 1," Peppers says.

Based on the clinical indicators and treatment, the patient's actual principal diagnosis should have been 038.9 (septicemia), Peppers says. But coders and CDI specialists need to query for that information because it is not obvious from the documentation.

In addition, coders or CDI specialists should query for potential secondary diagnoses. These should be: