Summer Reading: Physician Education Discussion Scenarios

by Laurie L. Prescott, MSN, RN, CCDS, CDIP

The following clinical scenarios illustrate where clarification would be indicated and include examples of differing communication methods.

Clinical example: The record states the patient was admitted for treatment of pneumonia and the patient was placed on IV antibiotics. A swallow evaluation indicates the patient is at risk for aspiration. The patient is placed on aspiration precautions and thickened liquids. For the coder to assign a code for aspiration pneumonia, the relationship between the pneumonia and aspiration needs to be documented in the record.

Approach #1 (verbal query): “Dr. Smith, I’m Jane from the documentation improvement team. Do you have a minute to work with me? This chart indicates the patient is at risk for aspiration and needs thickened liquids. Could you identify a probable etiology for her pneumonia? The physician responds, “It is probably due to aspiration.” The CDI specialist thanks the physicians and asks, “Could you please clarify that possible cause-and-effect relationship in the record?” She then reminds the physician that “Unlike outpatient coding, the use of possible or probable is permitted and can be coded for inpatient cases.” The physician immediately writes an addendum to his progress note: “Jane, thanks for your help.”  Jane should then document this verbal query and the results as part of the CDI notes for this account.

Approach #2 (verbal query): “Good Morning, Dr. Smith. It looks like you are busy today. I have a documentation clarification for you if you have a minute.” The physician responds, “Yes, I am busy and would appreciate it if we could talk later.” The CDI specialist responds, “No problem. I will leave a written query on the chart for you in case we do not see each other before you leave. I hope your day gets calmer.”

In both scenarios, the CDI specialist had the chance to talk to the physician and express the need for documentation clarification. However, the first scenario had the advantage of the physician immediately documenting an answer. In this case, the CDI specialist could have also taken the opportunity to education the physician on the importance of consistent terminology and could have asked him to use the term “aspiration pneumonia” throughout the rest of the stay and in the discharge summary.

In the second scenario, the CDI specialist informed the physician of the need to clarify documentation but additional follow-up is required to ensure the physician provided the clarification in the medical record.

As the saying goes, “don’t win the battle only to lose the war.” In this situation, it was better to back off politely. Insisting that the physician do it immediately risks angering and alienating the provider, which would make him or her less likely to cooperate in the future.

Editor’s note: This excerpt was taken from The Clinical Documentation Improvement Specialist’s Complete Training Guide by Laurie L. Prescott, MSN, RN, CCDS, CDIP.