Book excerpt: When to conduct re-reviews

By Laurie L. Prescott, MSN, RN, CCDS, CDIP, CRC

Your organization may have policies dictating the frequency of record review and re-review, such as conducting initial reviews within 24 hours of patient’s admission and re-reviews every 24 hours after that. The program should have practices in place which help CDI staff determine which records to target for such efforts. The staffing of your CDI department as compared to the number of admissions/discharges may also influence stan­dard practices of repeat reviews.

Repeat reviews should examine any physician orders written since the date of the last review for any changes in the plan of care or abrupt discontinuation of a treatment (which may indicate a possible condition was ruled out). Review any diagnostic test or study results, progress notes, and assessments for consistency, incongruity, or ambiguity, as set forth by the ACDIS/AHIMA physician query practice briefs as reasons for queries.

In general, not all records need to be reviewed every day, but repeat reviews should be scheduled for records in which:

• A principal diagnosis has not yet been determined
• A symptom is identified as the principal diagnosis
• An open query is pending
• A surgical intervention occurred
• The patient required a change in care level (either to an intensive care unit or shift from ICU to a general medical unit)

The mission or focus of the CDI department also influences the practice of repeat record re­views. Programs reviewing records primarily for reimbursement typically stop reviewing the record once no further changes in MS-DRG can be made. Those reviewing for severity of illness/ risk of mortality most likely review records repeatedly until discharge, to ensure every possible secondary diagnosis gets identified.

Editor’s note: This article is an excerpt from The CDI Specialist’s Complete Training Guide, Second Edition.