Q&A: How to determine how much clinical evidence warrants a query

Q: If an echocardiogram shows a type of trace/mild/moderate regurgitation, is that enough to query for that diagnosis? Or is this considered an insignificant finding?

A: I’m going to begin with some general guidance. First, CDI specialists should always defer to their program’s query policies to determine what is considered “enough to query” for a diagnosis to be coded. The next step for the CDI professional would be to familiarize yourself with the 2019 ACDIS/AHIMA “Guidelines for Achieving a Compliant Query Practice” brief. 

Secondly, in order for a diagnosis to be coded, it must meet the Uniform Hospital Discharge Data Set (UHDDS) definition of a principle or secondary diagnosis.

A note of caution, though: never query to get a diagnosis into the record just so it can be coded. There’s much more that should be considered, and we have to ask ourselves several questions, such as:

• Is the patient symptomatic in any way?
• What is being done to treat the condition?
• What is documented about the condition? 
• Is the provider describing the condition without naming it or is it not mentioned at all in the record? If the condition is not mentioned at all, are there valid clinical indicators for the condition in question?
• Why was the echocardiogram ordered to begin with? 
• Was this an incidental radiology finding for which the patient is not being evaluated, treated, or monitored? 
  
  • For example, if a patient came to the ED with signs and symptoms of a cerebral vascular accident (CVA), a head CT would be ordered. If the patient had received tissue plasminogen activator (tPA) afterwards, there are hospital protocols for a repeat head CT to be done within 24 hours status post tPA administration. 

So, the first question to ask would be: is this a routine follow-up head CT because of a hospital protocol? For example, a repeat head CT status post tPA which shows an incidental finding of a 2.5mm midline shift per the radiology documentation.

The next question would be: is the patient symptomatic? For example, the documentation shows that the patient is awake, alert, oriented x3, without any orders for increased frequency in neurological assessments, no additions in medications such as 3% IVF, mannitol or decadron, and no change in nursing interventions. All of these factors would not point to an acute episode of cerebral edema and a query would not be warranted just because a midline shift is an incidental finding on a radiology report.

Editor’s Note: Dawn Valdez, RN, LNC, CDIP, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at dvaldez@hcpro.com. For information regarding CDI Boot Camps, click here.