Guest post: Physician advisor role in assisting with clinical validation

By Cathy Farraher, RN, MBA, CCM, CCDS

Having a physician advisor on board to help either construct or review your query can help him or her to not only make the process a bit less painful for the provider or possibly negate the need for a query based on his clinical expertise, it also allows him insight into the ongoing needs of the facility in terms of documentation education.

Imagine a scenario in which you are a treating provider. You have documented your patient’s signs and symptoms, your differential diagnosis, and the treatment and further testing you feel the patient requires to achieve maximum medical improvement. You have worked very hard and are quite satisfied with the role that you played in providing this patient's care. At the end of your shift, as you are preparing to sign off to the next team, you receive a query from a CDI specialist questioning your documentation.

Imagine further, that the reasoning contained in the query does not speak to your medical knowledge and experience. And let's take that even a bit further. Imagine there are incorrect medical facts included in the query, or missing pieces of information that you already included in the chart that do validate your diagnosis. Are you going to be engaged in CDI efforts at that point? Or engaged in CDI efforts in the future? I think not.

CDI professionals need to use their best clinical judgement when deciding to send a validation query, since American Health Information Management Association (AHIMA) reminds us in its 2008 “Managing an Effective Query Process,” that:

“Providers often make clinical diagnoses that may not appear to be consistent with test results. …. Queries should not be used to question a provider’s clinical judgment, but rather to clarify documentation when it fails to meet any of the five criteria listed above—legibility, completeness, clarity, consistency, or precision.”

As CDI specialist, we bring to the role a very varied amount of education and experience. Regardless of our past experiences, we cannot even begin to pretend that we are as on top of clinical knowledge as a treating provider would be.

We absolutely require the input of a physician advisor who is a current treating physician and would have access to the knowledge that we would not possess. In the world of CDI, our departments reputation can be shattered by one inappropriate query. Knowing that, it is imperative that we recognize our own knowledge deficits, regardless of the amount of training and intelligence that we may possess. Although we may consider ourselves to be the specialists, we are unable to be effective without the respect and engagement of the clinical team.

Editor’s Note: Cathy Farraher, RN, MBA, CCM, CCDS, is a care manager at UC San Diego Health in California, and previously served as a co-chair for the CDI Practice Guidelines Committee for ACDIS, and as a co-leader for the Massachusetts ACDIS local chapter. Contact her at catarrina@gmail.com. Opinions expressed do not necessarily reflect those of HCPro, ACDIS, or any of its subsidiaries.