Q&A: Querying for unspecified diagnoses

Q: How much does your CDI team focus on unspecified codes if it does not have an affect on the case?  For example, a patient has hypertensive heart and chronic kidney disease (CKD), unspecified with clinical indicators of CKD stage 3, but this was not clarified/queried.  If we spend the time querying, it will not affect DRG/relative weight, severity of illness (SOI)/risk of mortality (ROM), length of stay, etc. I don't want to query just to query, but should we be looking to specify this if we have the support to do so? 

I'm doing some coding audits where I've had several diagnoses that could be specified but were left unspecified. When I looked at what CDI staff did on their end, they didn't attempt the specification either, likely because doing so would not have an effect on the typical outcome measures. 

A: “Our guide is if it needs to be clarified for coding, and the physician should know the answer, then we should query. In common conditions such as COPD [chronic obstructive pulmonary disease] and asthma the physician may just really not know the type. I do believe you have to prioritize your queries and not overkill. This could be a situation where you do some verbal/some written and educate to help physicians understand they should only be choosing an unspecified term when there really is no better option,” says ACDIS Advisory Board member Deanne Wilk, BSN, RN, CCDS, CCS, CDI manager, at Penn State Health in Hershey, Pennsylvania.

“We don’t query just to query,” agrees Rebecca R. Willcutt, RN, BSN, CCDS, CCS, CRC, CDI director at Cooper University Hospital in Camden, New Jersey. “If it affects DRG, SOI/ROM, mortality, outcomes, measures, HCCs [hierarchical condition category], we query. But we don’t have the staff or bandwidth to query for everything and I think you have to draw the line somewhere.”

Editor’s note: Members of the ACDIS Leadership Exchange group answered this question. If you have questions you’d like to pose to one of ACDIS volunteer boards, committees, or networking groups, contact Associate Editorial Director Melissa Varnavas (mvarnavas@acdis.org), or post it to the ACDIS Forum.