Q&A: Clinical definitions and core measure capture

Q: How have you handled situations when specialty physicians and hospitalists do not agree with diagnoses impacting core measures?

A: It becomes difficult because the clinical definitions of some disease processes are a little bit tricky. In specific scenarios such as acute myocardial infarction (AMI) and congestive heart failure (CHF), we’ve brought together a team of coding, quality, case management, and the physician groups involved to develop specific clinical definitions everyone can agree on. That cut down a lot of the back and forth that we’ve had along the way.

The coders got stuck in the middle of it. Coders don’t feel comfortable going up to a physician and saying, “Okay, Doctor Jones documented this as a STEMI, but you’re saying it’s not. You’re saying it’s not even an AMI.” That situation puts the coders and CDI staff in a very difficult position. We’re not the physician who’s ultimately responsible for the diagnosis of the patient, but we’re trying to dig through all the information.

We tried to select the most widely accepted clinical definition of CHF, because we don’t want to pick the most obscure definition that’s out there and narrow the field down to the point where we’re going to look odd when you compare us to other hospitals. By having an agreement about what that clinical picture is for a patient, a clinical definition for a diagnosis really sets the groundwork so that you don’t have all those conflicts back and forth in the chart.

It’s not a perfect world. We still have some cases that have to be clarified, but the nice thing you don’t have it happening all the time. You can follow the coding guidelines about the attending physician being ultimately responsible for the diagnoses of the patient and you can go back to that attending physician using the agreed upon clinical definitions.

Editor’s Note: Heather Taillon, RHIA, answered this question. At the time of this article’s original release, she was the manager of corporate coding support services at Franciscan Alliance in Greenwood, Indiana. This answer was originally published on JustCoding and is provided based on the limited information submitted to JustCoding.