Guest Post: Querying about other providers’ documentation

By Howard Rodenberg, MD, MPH, CCDS

Memo from the Full Disclosure Department: Lying behind my confident attitude, my devil-may-care good looks, and my abundant modesty lies a geek. I say this knowing full well what that entails, for a geek is different than a dork or a nerd. According to the website OKCupid:

“A nerd is someone who is passionate about learning/being smart/academia. A geek is someone who is passionate about some particular area or subject, often an obscure or difficult one. A dork is someone who has difficulty with common social expectations/interactions.”

I bring this up to indicate that after many years of attempting to be somewhat more normal, I’ve become comfortable with who I am: A middle aged guy who can admit to an encyclopedic knowledge of the works of Barry Manilow. It also means that I can also freely express my admiration for all things Star Trek in the most unambiguous terms without feeling like a dork. Because now, thanks to OK Cupid, I know what a dork really is.

Which, believe it or not, brings us to a small matter of CDI.

As we know, one of the rules of the coding system is that we can only assign a code based on what’s written in the chart by the attending physician. We can find useful information in nursing notes, nutritional consults, radiology reports, and pathology files, but we can’t code it unless it’s been noted by the attending physician.

As a result, we wind up sending queries to physicians asking if they concur with the tissue diagnosis of a pathology report, or agree with a particular finding on a CT scan or an MRI that might affect coding, reimbursement, and measure of illness severity. These queries usually take the form of “Doctor McCoy, the pathologist noted the presence of Pon Farr in the biopsy sample. Do you concur? If you agree, please indicate this in your progress notes and discharge summary.” To which, in Klingon, we most often hear in angry reply “Im qar’a’ pathologist Qel“ or “Dammit Jim, I’m a doctor, not a pathologist.”

(Yes, I know you cannot see Pon Farr on a tissue biopsy. But ponder the fact that you knew this and what it says about you.)

The simple fact is that doctors understandably don’t want to pass judgement on their peers, especially if it’s about something out of their own area of expertise. It’s inherent within physicians to greet such a request with caution. So if you ask them to agree or concur with something out of their ballpark, with medicolegal umpires officiating the game, they are going to eye that request with suspicion and may well let it go unanswered or actively reject the query. (This is true unless it’s an ER doc, where anyone can level a shot and it’s considered fair game. This is because most doctors did a month or two of ER during their residency and then went on to be specialists…translated as “person smarter than you”…while the ER docs were not bright enough to leave.)

I am not immune to this reluctance to confirm or deny that which I don’t understand. This is especially true given that I made it through my pathology lab course in medical school not by detecting differences in the cells I was looking at under the microscope, but because I was able to memorize the shapes and colors on the stained slices of tissue slides we were issued for class. For the record, liver is a purple triangle.

Physicians don’t feel that way just about pathology reports. We’re likely to encounter the same difficulties given any piece of conflicting or incomplete information in the record, whether it’s a radiology finding or a consultant note. I’m not in a position to second-guess the other guy, goes the thought process, so why are you asking me to do so? And yet clinically, we do this all the time, in that we generally guide our clinical efforts dependent upon the findings and recommendations from our pathology, radiology, and consultant colleagues. That certainly implies acceptance and concurrence. We’re just loath to say so. (Dr. McCoy told Captain Kirk he was “a doctor, not a bricklayer.” But he still found a way to patch up the Horta, and again it says something about you if you know what I mean.)

So in the end, it’s a matter of semantics, and there’s got to be a better term to use when we’re trying to get information into the chart. If “agree” and “concur” won’t work, what can we use? We need to look for words of agreement that don’t imply judgement but do imply active acceptance and integration into the plan of care. Simply saying the results are “noted,” I think, doesn’t quite do it. So perhaps we can ask, in a yes-or-no query, if the attending physician “acknowledges” the pathology report. The common use of the word implies an active thought process and integration into the plan of care. Maybe “accept” fills the bill, as it doesn’t imply an additional opinion but implicitly says the information is received, like a gift. “Recognize” may not be as strong, but the word implies integration of the idea with reference to past events.

To improve our responses to these sorts of queries, we’ve got to quit asking doctors to second-guess their peers. The right wording will help. Unless it’s an ER doc, of course, in which case it’s all fair game.

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at howard.rodenberg@bmcjax.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not represent HCPro or ACDIS.