Guest Post: New query guidance raises questions regarding clinical definitions

By Paul Evans, RHIA, CCS, CCS-P, CCDS

In my senior year of college the physician teaching our pathophysiology class gave the following assignment: “Define acute renal failure (ARF), based on signs, symptoms, lab findings, and cite abnormal laboratory values.”

I recall his exact words because of the subsequent undertaking I was compelled to take in order to “define ARF.” Bear in mind the year was 1989—the Internet was not available.

Initially, I thought the assignment would not be too difficult. I was incorrect. I went to the medical library found at least a dozen different ‘laboratory-defining’ definitions for ARF—all involving different levels of serum blood urea nitrogen (BUN), creatinine and potassium, and most with a key value pertaining to creatinine. Eventually, and after a lot of research and frustration, I settled on a definition that included, among other findings, the following:

• Sudden rise in serum creatinine of >1mg/dl/day
• Rapid BUN elevation > 20mg/dl)

My professor accepted this definition, but I believe he assigned this task to me for a reason—he wanted me to comprehend the complexity and variation involved in attempting to establish a ‘universal definition’ for a disease process.

Consider now, the significant changes in the philosophy and role of the coding professional and the CDI professional based as related to establishing so-called universal definitions within the recently released ACDIS/AHIMA “Guidelines for Achieving a Compliant Query Practice,” which states:

“When a practitioner documents a diagnosis that does not appear to be supported by the clinical indicators in the health record, it is currently advised that a query be generated to address the conflict or that the conflict be addressed through the facility’s escalation policy.”

This raises a number of questions, such as: Is it now incumbent upon such professionals to ‘screen’ diagnoses clearly written by a professional licensed to establish a diagnosis so that the condition may be ‘confirmed?’ Furthermore, if a facility takes this stance, would uniform and standard disease definitions be accepted universally for this purpose? Are the definitions used and cited in facilities to define, document and code key conditions universally accepted by third-party payers?

Regarding an escalation policy, how would (will) a physician react when a CDI reviewer or coder issues a query to confirm a clearly documented  diagnosis that does not meet a facility-accepted universal definition of acute renal failure, acute myocardial infarct, stroke, etc.?  How do we respectfully ensure the documentation in our facilities is ‘reliable’, while at the same time respecting the latitude and training of our physicians?

The definition I provided for ARF some time ago is outdated, now. Today, most use the 2012 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Acute Kidney Injury Definition (ARF means ‘acute kidney injury’) which defines AKI as:

• Increase in serum creatinine (SCr) by X 0.3 mg/dl (X 26.5 lmol/l) within 48 hours; or
• Increase in SCr to X 1.5 times baseline, which is known or presumed to have occurred within the prior seven days; or
• Urine volume 0.5 ml/kg/h for 6 hours

Needless to say, establishing standard definitions within our facilities will be challenging. True, the medical profession now diagnoses more often and more accurately conditions such as ARF, sepsis, stroke, and acute myocardial infarcts than they used to. Yet, as I reviewed the various journals and studied the disease definitions, I thought back to the now antiquated definition of ARF I cited while obtaining my RHIA, and considered the impact of new research and medical definitions on coding, medical research, and epidemiological studies. No doubt, the new ACDIS/AHIMA query guidance will require additional research and outreach as we partner with physicians to ensure the complexity of care is properly classified.

Editor’s Note: Evans, (at the time of this article's original release) supervisor of clinical data integrity in the quality department at California Pacific Medical Center in San Francisco, California, wrote this article in response to a discussion on the ACDIS message board CDI Talk. He served as a reviewer for the 2012 revision of The CCDS Exam Study Guide, and is a member of the CA ACDIS chapter leadership team.