Tip: Review Records with an Eye on the Clinical Truth

Editor’s Note: This article was originally published in CDI Monthly, by DCBA, Inc., and shared on the social media network LinkedIn. It has been adapted from its original and is republished here at the invitation and permission of the author and participants.

“Many CDI programs have set their goals as: accurate coding, maximum reimbursement, increased case mix index (CMI), and better risk-adjusted scores,” says Cesar M. Limjoco, MD, vice president of clinical services at DCBA, Inc. in Atlanta, Georgia. “But are they missing the mark? Are they setting their targets low and setting themselves up for a fall?” Limjoco asks. “The goal sets the tone for one’s actions. The end justifies the means.”

CDI programs with preset agendas can slip into focusing solely on those priorities at the expense of the clinical truth, he warns. Like a racehorse wearing blinders to limit distractions, CDI specialists can be blinded to all but those pre-set goals before them. Without a broad perspective they may have a tendency to arrive at incorrect conclusions, he says. For example, if these end goals take precedence it becomes easier to see (and query for) a variety of diagnoses that may not be “true” given the broader picture of the patient’s condition, Limjoco says.

“As you may have heard before, medicine is both an art and a science. A provider does not come up with a diagnosis just from laboratory and other workup. There are false positive and false negative results. The provider has to marry the workup results with the clinical picture of the patient,” he says.

Consider the nuances of querying for sepsis solely because the patient’s presentation satisfies the 1992 SIRS criteria, he says. The CDI specialist may only see that the documentation meets clinical criteria for sepsis so they query for it and the physician documents it and it gets coded. “But was the patient really in sepsis?” Limjoco asks.

The same thing could be said about querying for acute kidney injury in the presence of a creatinine bump of 0.3 mg from baseline. “Never mind if the creatinine quickly returns to baseline within four to six hours of volume correction; never mind that studies have shown that there is no kidney injury in those cases and that small bump is reflective of hemoconcentration,” Limjoco says.

CDI specialists have a tendency to query for acute blood loss anemia in a patient with a 4 gm drop in hemoglobin despite the fact that the patient’s condition may be due to hemodilution from the infusion of intravenous fluids, which is often seen in patients undergoing surgery. A lot of infusion pre-, intra- and post-op will expand the intravascular plasma volume, which will make the blood cell mass look small and will be reflected as dilutional anemia, he says, “which is really a misnomer, because it is not really anemia in the first place.”

In a patient with a small elevation of troponin, coders and CDI specialists may jump to query for acute subendocardial myocardial infarction despite the fact that it may actually be due to the patient’s kidney disease, says Limjoco. Or, it can be from some other condition causing a troponin bump.

Another frequent query for acute respiratory failure comes from a patient whose oxygen saturation dipped down to 93%, he says, but CDI specialists need to see the whole picture, to check if the patient was in distress and if there were signs of hypoxia or hypercapnia present. Oxygen saturation measurements from pulse oximetry are not very accurate and may need clinical interpretation by a provider for significance.

A drop in albumin can send everyone scurrying for a diagnosis of malnutrition. But, there are other things that can precipitate a drop in albumin.

“Queries like these become collateral damage when the CDI quest falls short of what the true mission should be—to get to the clinical truth. When actions are motivated by the right reasons, then one does not stray from the right path. And wouldn’t you know it, if you set your sights higher to capture the clinical truth, accurate coding, optimal reimbursement, and true risk-adjusted scores follow. It’s simple—just do the right thing,” Limjoco says.

Doing the right thing for the right reasons—the quest for clinical truth—can also help with Recovery Auditor defense.

Recovery Auditors simply take back (deny) any claim that is not clinically valid, so parameters for querying must be strict, says Lucia Skipwith Lilien, RN, CCDS, C-CDI, CP-DAM,CDIP, CDI Supervisor at Health First, Inc., in Melbourne, Florida. “Providers should understand that even if they write a diagnosis, it might not get coded.”

“Recovery Auditor denials, and denials by other agencies, will always be problematic,” says Limjoco. “But on appeal the crucial issue comes down to the underlying ‘clinical truth’ of the medical record,” he says. Did the physician and the facility perform the care needed for the conditions presented and does the medical record accurately and completely reflect that care?

“Even the most altruistic programs meet suspicion and mistrust by providers,” says Skipwith Lilien. So, to combat this, CDI programs should keep the scope broad and quality-centric (on the entire medical record). “In this time of austere budgets, the hospitals have a right to ask the provider why he [or she] used services that cost and extend patient stays.”

In fact, asking such questions ultimately helps defend the medical record against claims denials and auditor investigations, she says. “CDI efforts do many great things for providers, from reduction of hospital acquired conditions to capturing patient severity of illness and risk of mortality concerns. All of which helps the physician and the facility look good, shows the quality of care provided to the patient, and helps the hospital get paid… to me that’s where the win/win relationship is.”