Note from the Instructor: Everyone learns when you talk turkey

By Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC

It was early morning and I was up to my elbows (literally) inside a huge turkey. No one else was up but the doctor in our family. We chatted as I dressed the turkey and he answered his charting deficiencies on a laptop nearby.

The first time I cooked a turkey (many years ago) I pulled the neck out but did not know about that second bag of goodies inside, I told him. I cooked the bag and did not notice until it came time to carve the bird. The Butterball directions could have been clearer, I grumbled.

I remember my mother-in-law telling me the secret to a good turkey was to pull out the kidneys as they give the bird a bitter taste if left inside, I continued. She also told me to cook the bird breast side down.

He asked if I did as she instructed. Yes, I cook my turkey upside down but have never found the kidneys to pull them out, I replied, musing, “I don’t even know if turkey’s have kidneys. Have you ever heard of a turkey with acute kidney injury?”

He laughed and said, “I work with CDI specialists who don’t understand AKI. Perhaps I need you to come and talk turkey with them.”

How could his CDI staff not understand AKI? I wondered. It’s a diagnosis that’s so common to our query and clinical validation practice.

He looked up from his laptop and said, “See, I answered this query three times and they still won’t let it go.” He explained how he documented acute renal failure and a query was placed to further differentiate the renal failure; he answered AKI and the CDI specialist reassigned the same query, as he was not satisfied with the answer.

I laughed, and explained that it seemed there were two issues to contend with. First, the CDI specialist should not continue to reassign the same query hoping for a better answer. CDI staff should not harass or prod providers. Secondly, perhaps the query needed to be rewritten in a clearer manner.

I then explained the query was probably placed to identify the etiology of the renal failure, likely looking for an intra-renal process such as acute tubular necrosis (ATN). I asked if the patient had any clinical indicators to support an ATN.

He said yes, she had received IV contrast for imaging prior to the rise in creatinine and did not return to baseline with hydration. He described urinalysis results demonstrating the presence of brown casts in the urine.

Then, we reached the point when the learning happened.

“I agree with the premise of the query and I answered AKI,” he said.

I asked, “Do you understand that within the code set AKI is considered the same as acute renal failure?”

Then he gave me that doctor sigh and said, “Well, that doesn’t make sense to me. I see the two terms as meaning something very different. No wonder they keep asking me for further differentiation.”

He saw the terms of acute renal failure and acute kidney injury as having two very different meanings. No one explained why these questions were being asked and why differentiation of the etiology was so important to support severity of illness/risk of mortality, and the actual story of the patient, just like no one had ever explained to me there were two bags of goodies stuffed inside a turkey. 

Just as the Butterball instructions could be clearer, so too, could the education provided to my physician have better described why such queries were needed. The CDI staff should have engaged more fully with the provider, offering education related to the documentation of renal failure and the importance of identifying the etiology—using terms that can be coded accurately.

Providers need to understand the “why” behind our questions and learn how their words translate or don’t translate to the terms found within the code set. We cannot just ask the questions without offering education as to the reasoning behind it.

He laughed, answered the query, and then said, “Well now I understand what they are asking for. I wish they had taken the time to explain it months ago. Honestly, it’s like you people are speaking a different language.”

I write this story to remind you that we should be “talking turkey” with our providers. Engage with them regularly, offer education both formally and informally to ensure they understand our queries and the motivation behind them. If you find you are repeatedly asking the same types of questions, take the time to speak with the provider. You may find that with a little discussion, you both learn how to better “dress the turkey.”

Editor’s note: Prescott is the CDI Education Director at HCPro in Middleton, Massachusetts. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps, visit www.hcprobootcamps.com/courses/10040/overview.