Q&A: Post-discharge query compliance

Q: One of our inpatient coding team members recently sent the following post-discharge query and our team is split on whether it’s compliant or not. Could you help us settle the debate? Here’s what the query said:

Dear provider,

Per summary, rapid response was called on DATE. Noted to be hypotensive 85/50, 71/50. Patient moved to ICU to start pressors. BP 64/40. Levophed max dose. BP responded but then dropped again, started on neo at max dose as well as Levophed.

Is there a diagnosis for multiple pressors needed?

Please add the findings to the discharge summary.

Thank you,

SIGNATURE

A: There are a few points here to question. First point is that there are no quotation marks around any portion of the clinical scenario provided. Anyone reading this cannot tell if the clinical statement is a direct quote documented by the provider or if it is written by the coder. Secondly, “hypotension” is a diagnosis listed in the query. Was that diagnosis documented by the provider? Or was this a new diagnosis introduced by the coder?

I think the best approach is to rewrite the query to provide more clinical context for the provider as well as anyone who may be auditing this record.

Again, without having the actual clinical scenario here, other than what’s provided, I will add clinical content, indicators, treatments, etc. to make this query more effective and robust.

Query example:

Dear Dr. XYZ,

Patient PQR was admitted on DATE with “pneumonia with possible sepsis.” On admission: WBC 20, lactic acid 4.2, Temp 102, HR 120, Resp rate 24 and BP 100/50 Cultures obtained, CXR with pleural effusion. Started Levofloxacin 750mg IV daily, NS @100cc/hr, O2 @4l NC in ED.

Patient has a history of COPD on home oxygen (2l nc), CAD, HTN, cardiomyopathy and Type 2 diabetes

DATE rapid response summary: “Called to bedside @ 0810 for hypotension and lethargy. Patient confused and restless with shortness of breath. HR 140 BP 85/50, resp rate 36. Placed patient on non-rebreather, Dr XYZ at bedside, ordered NS 1l bolus, labs, EKG. Portable CXR, transfer to ICU.”

DATE per Dr. XYZ summary 0830: “Rapid response called. Patient noted to be hypotensive 85/50, lethargic. Transferred to ICU to start pressors.”

DATE 0835 Nurses note: “Manual BP 71/50 Levophed max dose, Dr PQR at beside for A-line placement. IVF 1L bolus.”

DATE 0842 Nurses note: “Manual BP 64/40 Added Neo synephrine max dose.”

Based on the clinical indicators above and your professional judgement, can an associated diagnosis be documented?

• Sepsis with septic shock 2/2 pneumonia
• Sepsis with septic shock with unknown source of infection
• Other shock (Please specify etiology) _____
• Other explanation of clinical findings (please specify) ____

By adding the admitting diagnosis, past medical history, Systemic Inflammatory Response Syndrome (SIRS) findings, treatment, and provider notes, a more clear clinical picture is painted. The provider is given the relevant clinical content to make an informed professional opinion without having to search through the record. The clinical content supports the diagnosis options provided.

In this case, two provider response options are offered as an “other” to capture either a different type of shock or a different explanation of the clinical indicators. The query question is asked in a non-leading format, allowing the provider to offer an unbiased professional response. Offering sepsis as part of the response option also validates (if selected) the “possible sepsis” listed on admission.

Note: if the provider selects “other shock – hypovolemic” (for example, not an option that included sepsis) and the clinical indicators in the record support sepsis, an additional sepsis validation query may be needed to solidify that diagnosis.

Editor’s note: Sarah Matacale, BSN, RN, CCS, CCDS, the query education and compliance specialist at HCPro, ACDIS, and AHIMA, answered this question. Contact her at sarah.matacale@hcpro.com.