Q&A: Clinical indicators for provider judgment
Q: I’ve always thought that, as long as the clinical indicators support the condition you’re querying for, providing all the options for the specific type/specificity of that condition allows the provider to use their clinical judgement. Is this correct?
A: The direction within the ACDIS/AHIMA “Guidelines for Achieving a Compliant Query Practice” brief clearly states that we shouldn’t offer choices that are not clinically supported. For example, if you are querying for the type of heart failure and the ejection fraction is 50%, I would not offer systolic heart failure as an option as it does not fit the clinical indicators.
Offering choices that are clearly incorrect can also be frustrating to physicians and hurt your provider engagement in the long run.
Take a look at the example on p. 18 of the practice brief:
Dear Doctor,
Acute congestive heart failure was documented within the progress note dated xx/xx.
Clinical Indicators: Previous echo from last week’s visit indicates an ejection fraction of 35%.
Based on your judgement and review of the clinical indicators listed below, can you please select the most appropriate diagnosis?
- Acute systolic congestive heart failure
- Acute systolic and diastolic congestive heart failure
- Other explanation of clinical findings (please specify) ____________________
- Clinically undetermined
I’m not sure how long you’ve been working in CDI, but when I started, we were instructed that our answers had to offer choices that would and would not impact reimbursement. Meaning we had to offer an answer that would lead to CC/MCC capture but also an answer that wouldn’t. Then, of course, we needed to include “other” and “clinically insignificant.”
I remember staring at the form trying to figure out what to add to fill in the blanks. More often than not, the answers I added weren’t accurate to the patient’s situation and I was extremely embarrassed to offer them as options. I didn’t want to lose my credibility when speaking to the providers.
I think the practice brief supports the fact that CDI and coding professionals are critically thinking individuals who can use accepted diagnostic criteria and apply them to the query process.
Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CCDS-O, CDI education director at HCPro in Middleton, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps, click here.