Tip: Create a policy for CDI/coding conflict resolution

A physician documents “renal insufficiency” in the progress notes and H/P. Based on the serum creatinine values, the CDI specialist generates a physician query for additional clarification (i.e., “acute renal failure?”).

 

The attending physician documents “acute renal failure” in the next progress note, but subsequent notes provided by the attending physician’s partner state “renal insufficiency.” The diagnosis is not documented in the discharge summary.

 

Since the condition “acute renal failure” was documented only once in the record, the coder feels that the record does not adequately support code assignment. However, the CDI specialist feels that the lab values and treatment plan do support the code and notes that it’s the only MCC for the case. Omitting this code results in a lower-weighted DRG assignment.

 

A discussion between the coder and the CDI specialist results in a standoff: The coder feels that coding the condition would be upcoding, and the CDI specialist feels that her efforts were not successful.

 

The case is referred to the team’s physician advisor, who reviews the record from a clinical perspective. Based on the patient’s condition and treatment plan, she feels that “acute renal failure” accurately describes the circumstance and meets the clinical definition of acute renal failure. She then contacts the patient’s attending physician and discusses the case.

 

A retrospective query is generated to the attending physician, who then adds an addendum to the progress notes and the discharge summary.

 

Editor’s Note: Lynne Spryszak, RN, CPC-A, CCDS, CDI education director at HCPro, Inc., in Marblehead MA, provided this tip in her article HIM, CDI programs require ‘TEAM’ approach published in the April 2010 edition of the CDI Journal. Contact her at lspryszak@hcpro.com.