Note from the Instructor: Beware of common compliance pitfalls

By Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC

Compliance is a “shady” subject. Those that have attended my Boot Camps know I refer to the Official Guidelines for Coding and Reporting and AHA Coding Clinic as the “Less than sexy 50 shades of grey.” I say this because two people can read the same guidance and interpret it differently. I encourage organizations to be consistent in the “shade of grey” they interpret; meaning everyone within the organization should follow the same practice. Although, I consistently find that organizations strive to do the right thing, I do see two common issues related to compliance that can hurt an organization. Oddly enough, these two issues use contradicting logic. 

The first practice works to stretch the boundaries of compliance. Often, we justify activities as being compliant because we see the end goal as being desirable for the common good. The “ends justify the means.” Be very careful to avoid this trap. Just because we know what documentation is needed, does not mean we can lead or influence the desired wording.

I have heard people justify the use of leading queries, using excuses that they are a nurse and it’s okay for them to lead a provider to the correct answer. CDI specialists coming from a nursing background must remember that in the role of CDI, we are not part of the patient care team and cannot be seen as influencing the provider related to diagnoses or influencing the plan of care. That is not our role.

For most clinical professionals the focus of patient care to include the assessment, planning, and implementation of care is a core skill that is not easily given up. It’s often a difficult transition when one becomes a CDI specialist to realize we cannot participate in this aspect when in the role of CDI. 

Physician advisors struggle with this issue as well.

I have been asked numerous times by physician advisors if they can just answer other physicians’ queries or dictate discharge summaries for their peers. These physician advisors says they know what needs to be written and it’s easier if they do it themselves instead of bothering the treating physician. Furthermore, the provider being queried often tells the CDI team to, “just write what you want written.”

We, of course, know this is considered noncompliant and cannot be done. Just like CDI nurses, those in the physician advisor role are not actually caring for the patient, they are unable to adequately provide diagnoses or direct the plan of care.

We must depend upon the provider caring for the patient to provide the needed documentation, otherwise it appears we are leading the caregiver to provide the specific documentation.

I have also visited organizations in which the CDI staff update the problem list, or write the discharge summaries, handing over the finished project for the provider to simply sign to authenticate. They justify this activity by giving the provider an opportunity to edit and make changes. Yes, we work to obtain complete and accurate documentation within the medical record and we know the importance of a well written discharge summary, but we are not the ones who provide that documentation—the treating physician is. We need to follow the guidance and rules of compliance.

How accurate can that discharge be if it’s written by an individual who never cared for the patient.

The second mistake I’ve encountered are organizations that try so hard to be compliant that they actually take on noncompliant practices which lead to coding errors. I have heard organizations make statements such as:

“We never query for or code the diagnosis of encephalopathy because it is ALWAYS challenged. We just choose to leave it off the claim even if documented.”

“We never assign DRGs identifying OR procedures unrelated to the principal diagnosis (981,982,983, 987. 988). We re-sequence to identify a principal diagnosis that matches the procedure.”

“We never speak to our providers about reimbursement methodologies…”

When I question such statements, the reasoning is always, “we want to be compliant.” The issue is that we should not try so hard to be compliant that we ignore the guidelines or direction set to assist in clarification of these situations. I urge people to use caution when they make blanket statements related to what should never be done.

The best practice is to stay informed. Read the Guidelines. Understand the coding conventions. Stay up to date with AHA Coding Clinic advice. When you encounter advice that could be interpreted as many different shades, seek to clarify how the guidance should be interpreted. If you are unsure, seek further clarification from Coding Clinic. When the advice or guideline is difficult to understand, coders and CDI specialists should discuss how the rules should be applied and encourage consistency throughout your organization.

Lastly, be open to different interpretations, challenge the status quo if you feel a rule is being interpreted incorrectly. The only way we learn is to share our opinions and be willing to change them if appropriate.

Editor’s note: Prescott is the CDI Education Director at HCPro in Middleton, Massachusetts. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps, visit www.hcprobootcamps.com/courses/10040/overview.