Answers from the Forum: Using criteria from the NQF, AHRQ, and CDC for queries

Q: Should CDI take the criteria from the National Quality Forum (NQF), Agency for Healthcare Research and Quality (AHRQ), and the Centers for Disease Control and Prevention (CDC) into consideration when querying for CAUTI, CLABSI, etc. to avoid unintended consequences, such as linking sepsis to a central line when the CDC criteria are not met?

A: I absolutely agree that these other considerations need to factor into the determination about whether a query should be placed, and also when a condition is valid for event reporting via coding. We should not be pushing towards the short-term goals of adding CCs when they are questionable and do financial and profiling harm to the facility in terms of value-based reimbursement methodologies and public profiling.

In fact, I use the NQF as an example in my Boot Camps to discourage students from placing a query for a post-operative ileus for a patient with abdominal surgery until day five. After all, if the NQF considers a lack of a return of bowel function integral to the abdominal surgery until day five, we should too.   

Sometimes you’re just playing the odds, though. Seventy to 80% of urinary tract infections (UTI) in the presence of a catheter are, in fact, due to the catheter. This highlights, however, the importance of immediately getting a urinalysis and culture at the point of contact to help demonstrate the accurate present on admission (POA) assignment. You’ll have a hard time convincing me that when we place a Foley at 2p.m. and a new onset UTI is determined at 3 p.m., that it’s a Foley acquired condition. Yet, if you aren’t paying attention, it could end up coded as such. 

The CDC reporting guidelines do partially avoid these pitfalls as the criteria actually specify the timetable of events which must occur prior to abstracting for infections reporting. Caution is warranted, however—what an infection control specialist can abstract is very different than what a coder can report. Coding requires specific language from a treating physician while CDC reporting only requires certain criteria are met regardless of the physician documentation. 

Pressure ulcers are another good example of the issue. Ask me if I believe a homeless patient admitted on Thursday did not already have a stage 1 or 2 decubitus ulcer discovered on Friday. Spoiler alert, I don’t. You wouldn’t take a patient sleeping on the sidewalk, put them in a therapeutic hospital bed for only one day, and somehow cause a pressure ulcer. What happens in these cases is that the pressure ulcer was already present, but it was difficult to identify visually on inspection and it became observable on day two. The hospital didn’t cause it. I think we forget sometimes to apply the “common sense” test to our documentation and coding. 

All that said, care should be applied when trying to apply CDC or NQF guidelines to coding as coders cannot follow those guidelines.

I still absolutely encourage you to work with the other departments in your facility (i.e., quality, coding, etc.) to educate both the coders and the CDI so that you’re all on the same page with regards to when it makes sense for the facility to report a condition.

Ultimately, though, for CDI and coding, the physician has the final say, not the criteria.

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CRC, CDI education specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.