Q&A: Query options for lack of clinical indicators

April 25, 2013

Q: The physician documented mild bronchitis treated with Zithromax in the progress note on day two of the patient’s hospital. I looked for clinical indicators and the only documentation I found in the nursing notes was that the patient had a non-productive cough on admission. The patient’s chest x-ray is clear, oxygen (O2) saturation was 96-100% on room air, the physician did not order O2, and lung sounds were clear since admission. Would you query the physician about this diagnosis, and if so, how?

A: ACDIS/AHIMA released “Guidelines for Achieving a Compliant Query Practice,” in the February edition of the Journal of AHIMA and the April edition of the CDI Journal. The document states that coding or CDI staff should query the physician if a diagnosis is not supported by clinical indicator(s) in the medical record. Here is the excerpt from the practice brief:

“The focus of external audits has expanded in recent years to include clinical validation review. The Centers for Medicare & Medicaid Services (CMS) has instructed coders to ‘refer to the Coding Clinic guidelines and query the physician when clinical validation is required.’ The practitioner does not have to use the criteria specifically outlined by Coding Clinic, but reasonable support within the health record for the diagnosis must be present. When a practitioner documents a diagnosis that does not appear to be supported by the clinical indicators in the health record, it is currently advised that a query be generated to address the conflict or that the conflict be addressed through the facility’s escalation policy.”

Regarding this case, a query is in order if the goal of your CDI department is record accuracy. However, most CDI and coding departments have limited resources so one also needs to consider the impact of this diagnosis on the DRG assignment. Bronchitis doesn’t add a CC or MCC. Because the DRG isn’t affected, some organizations may not seek clarification. The larger issue is when an “unsupported” diagnosis adds a CC or MCC, and in those situations the physician really should be queried to ensure the documentation supports the coding.

I like that you listed the patient’s presentation/symptoms and didn’t just rely on the negative x-ray when reviewing the record for clinical indicators. I would also suggest reviewing the emergency department (ED) notes (if the patient was seen in the ED), just to be sure there isn’t something to support the diagnosis of bronchitis as well as the history and physical notes, including the physician’s review of systems. If you still can’t find any support for the diagnosis of bronchitis then I might pose a query as follows:

“Dear Dr. Ericson, The diagnosis of bronchitis appears in the medical record (put the location). The patient is also receiving Zithromax presumably for the bronchitis. In the next progress note or the discharge summary can you please confirm the diagnosis of bronchitis by reiterating its associated clinical indicator(s) or state if it has been ruled out?”

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., answered this question which was originally published on the ACDIS Blog. Contact her at cericson@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview.

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