Speaker Q&A: Limjoco and Estes talk query auditing

Editor’s note: Cesar M. Limjoco, MD, and Kelli A. Estes, RN, CCDS, will be presenting “The ultimate test for queries,” on Day 1 of the ACDIS conference. Limjoco is the vice president of DCBA, Inc. in Indianapolis, Indiana. He has more than 25 years of consulting experience, serving in his current position since 2005. Estes is a clinical documentation specialist consultant for DCBA, Inc., an Atlanta-based company founded by the late Robert S. Gold, MD. She has 23 years of experience in nursing and 16 years in CDI.

Q: Where did the idea of “capturing the clinical truth” originate?

Limjoco: I was presenting to the medical executive committee at a medium-sized hospital on the roll out of a CDI program implementation. The chief executive officer and the chief medical officer decided to stay and talk to me after the presentation. The chief medical officer wanted to get to the core of what CDI is really all about. He understood from my presentation how it affected resource utilization, level of care, reimbursements, case mix index, facility and provider profiles, quality measurements and patient care; but, he wanted to dig in to the core of the matter. He asked me: “If a provider documents consistently a diagnosis or diagnoses throughout the patient record (from the history and physical [H&P], progress notes, and discharge summary), will that suffice?”

I responded that it needed to be clinically supported.

He proceeded to say: “As the devil’s advocate, what if an elderly skilled nursing facility (SNF) patient referred to the ED has features, e.g., fever, leukocytosis and hypotension, that may be due to sepsis. (This was early on during the sepsis 1.0 criteria with two of the four features defining sepsis). Sepsis is documented clearly from the H&P, progress notes, and discharge summary. By the way, patient was well enough to be discharged back to SNF after 48 hours.”

I responded, “It should be based on the clinical truth. Usually elderly SNF patients may present with altered mental status and are referred to ED for suspicion of sepsis. In the ED, patient is seen to have fever, leukocytosis, elevated creatinine, urinary tract infection on urinalysis and even hypotensive. But, after four to six hours of IV fluid replacement, the patient’s altered mental status, hypotension and creatinine goes back to normal baseline. The patient is not really septic. Hypovolemia with some UTI is what the patient only had.”

This resonated with the chief medical officer.

He said: “That’s it!”  

And when I asked, “What did I say?” he responded, “You said it’s about the clinical truth!”

Q: What worries CDI specialists most in terms of writing compliant queries?

Estes: CDI specialists are fearful they will lead the physician with their queries. Coders have been querying providers as part of their work for years, but when nurses embrace the role of CDI specialist it is often difficult to determine where the sweet spot lies in writing clinically sound queries and still follow the recommended guidelines for issuing a non-leading or compliant query. 

AHIMA and ACDIS have published industry standards for query/clarification practices and all professionals involved in the query process need to adhere to the guidelines regardless of credentials, position, or title. We are all trying to speak the same language with a slight difference in dialect so we need to use the same guidelines to get there. 

The clinical language and the coding language have just enough difference to make things tricky at times. Typically, CDI specialists who are nurses have a working knowledge of coding and though they practice under the same guidelines as coders to avoid writing leading queries, they often struggle with being restricted from using more straightforward clinical language in their communication with providers.

Q: Which diagnoses seem to give CDI specialist the most difficulty in terms of drafting an effective query? 

Estes: Queries for clinical validity are commonly noted as challenging because CDI specialists are concerned they will be found guilty of questioning the provider’s clinical judgment. Clinical validity queries have increased over the last few years due to increasing denials.

To manage denials more efficiently, CDI teams are initiating processes to query providers for additional clinical support in those cases at high risk for denial. These type queries are very important and must be incorporated into the CDI process appropriately to help providers understand this is not to question clinical judgment but rather to clarify documentation that may need additional clinical support to withstand scrutiny. To support such processes, hospitals should also initiate escalation policies with the assistance of a physician advisor.

Q: What do you think the biggest change has been in terms of CDI queries in the past 10 years?

Limjoco: I believe the biggest change is the increasing need for queries to be more clinically valid. Clinical validation takes the worry away from leading queries. There is growing realization that CDI specialists are required to not only go for the low hanging fruits of CCs and MCCs but they need to validate what is documented in the health record in order to withstand scrutiny. It’s not enough anymore that a diagnosis is documented appropriately, but it has to be consistent with the patient’s clinical picture. It’s not just a question of meeting clinical criteria or parameters, but is there any other factor or condition that signifies the true nature of the patient’s condition.

To start, why is the patient in the hospital? This is a question of identifying the principal diagnosis. Is the level of care appropriate? We have seen a lot of wasted hours used up by the CDI team and leadership, trying to figure out what is the principal diagnosis. Many of them are not only matters of documentation ambiguity but truly are of inappropriate level of care. The CDI scope of queries are extending to medical necessity for the level of care, hospital acquired conditions, core measures, and other quality measures. By no means are CDI specialists going to take over quality, utilization, care management, and risk management. But, they can collaborate with their corresponding peers in making sure that the documentation is in sync with the clinical truth. It’s all about the story being cohesive and capturing the true clinical condition.

Editor’s Note: Contact Limjoco at dr_cesar_limjoco@icloud.com or Estes at k.estes@yahoo.com.