Q&A: Mentioning SOI/ROM and support level of care in queries

Q: Is the statement “please document in a progress note to capture the severity of illness (SOI), risk of mortality (ROM) and care needed for this patient” appropriate to use in a query? In general, is it appropriate to mention SOI/ROM and support level of care and profiling when querying physicians?

A: Many mature CDI departments know that providers respond better to discussions regarding the SOI/ROM than they do regarding reimbursement (i.e., discussions of dollars). Most providers feel they treat the “sickest of the sickest” and pointing out how their documentation affects quality measures and reporting illustrates the direct benefit of CDI efforts for them and their patients.

However, these discussions also need to explain the relationship between documentation, reimbursement, healthcare quality, profiling, etc. CDI staff should share information regarding the importance of SOI/ ROM during formal training sessions with the medical staff and as the opportunity arises during impromptu interactions with individual providers on the hospital floors.

I subscribe to the concept of keeping the query as concise and simple as possible. Therefore, I would not include this type of language as part of the query process itself.

As an additional note of caution, since the MS-DRG and APR-DRG reimbursement systems are based on the “severity” of the patient’s condition—the more “severe” the patient’s condition, presumably, the higher the reimbursement—providers may associate the discussion with a secret code of sorts. “When I say SOI/ROM, you know I’m really addressing reimbursement.”

The 2013 query practice brief, Guidelines for Achieving a Compliant Query Practice Brief states:

“A query should include the clinical indicators…and should not indicate the impact on reimbursement.”

Circle back to the provider if he or she fails to respond to a query and explain why the query was placed and how a change in documentation could have positively affected reimbursement, healthcare quality, profiling, etc., reinforcing the initial education provided. Physicians often respond to concrete examples. When such is associated with their own documentation, even better. Timing such discussions and including additional illustrations of both effective and deficient documentation to prove your point helps take the emphasis off a specific situation (which may be deemed leading) and places it within the realm of overall program goals and general documentation improvement.

Also, I always say to trust your gut. If it feels a little murky to you, then don’t do it. Nothing is worth compromising your integrity and ethics.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Director at HCPro in Danvers, Massachusetts responded to this question.