Q&A: Conducting a health record review

A: When I teach the CDI Boot Camp, I ask the students to focus on the following three pieces of information for every case.  You may want to make a “cheat sheet” as you work through your records. Consider keeping a pad of scratch paper nearby. Be sure to note where each of these elements were located in the health record for future verification and who authored the documentation in the event that there is a conflict between the attending provider and a consulting provider that needs clarification.

 

1. Identify the principal diagnosis (Pdx). Take note if it is a symptom diagnosis. You will want to conduct a daily review of that record until the physician documents a definitive Pdx. If it is an incomplete diagnosis such as “heart failure,” query the physician. In this case you wouldn’t be querying to change the DRG but to employ consistent CDI practices across all cases. You should always query for an incomplete diagnosis (not only when specification of systolic/diastolic would add a CC).

 

Be watchful for cause and effect diagnoses that may require additional documentation from the provider to establish the link between diagnoses like diabetes and its manifestations, or complications from care that can alter the principal diagnosis assignment.

 

2. Determine if there are additional diagnoses or related documentation that qualify as either a CC or an MCC. You can use the alphabetic list of CCs/MCCs in the DRG Expert to determine whether a diagnosis is a CC or an MCC. You may have a missing, vague or incomplete diagnosis that requires a query to add a CC or MCC in which case I would make a note of it.

 

3.  Determine whether a physician performed a surgical procedure that moves the case to a surgical DRG.  These are referred to as a “valid” surgical procedure in the DRG Expert.

 

For example, consider a Pdx of fever of unknown origin which maps to DRG 864. Because there is no additional diagnosis in the health record there is no related CC/MCC. However, further investigation by the CDI specialist reveals that a bone biopsy (ICD-9 code 77.49) was performed. While the physician did not link the biopsy with the fever there may be additional opportunity to clarify the record in this case. If you take the principal diagnosis and add the surgical procedure it results in assignment of DRG 855.

 

Editor’s Note: This question was answered by Cheryl Ericson, MS, RN, CCDS, CDI-P, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director at HCPro, Inc., in Danvers, Mass. Contact her at cericson@hcpro.com. For information regarding the CDI Boot Camp or ICD-10 for CDI Boot Camp visit http://www.hcprobootcamps.com/courses/10040/overview.