Guest Post: AHIMA addresses clinical validation, coders and CDI defining diagnoses

by James Kennedy, MD, CCS, CDIP

AHIMA recently published a clinical validation practice brief in the July 2016 Journal of the American Health Information Management Association, available to AHIMA members on their website. In it, they state:

Although it is tempting for CDI and coding professionals to define diagnoses for providers, doing so is beyond their scope. For example, it is not appropriate for a CDI or coding professional to omit the diagnosis of malnutrition when it is based on the patient’s pre-albumin level rather than American Society for Parenteral and Enteral Nutrition (ASPEN) criteria. Many practicing physicians have not adopted ASPEN criteria and there is no federal or American Medical Association (AMA) requirement stating that ASPEN criteria must be utilized by a physician in making the diagnosis of malnutrition.

While this is technically true, given that CDI and coding professionals are not licensed to practice medicine, nor are involved with direct patient care under most circumstances, they still should be their facility’s representatives to encourage the medical staff, as a whole, to adopt facility-wide definitions of challenging clinical terms (e.g., sepsis, malnutrition, acute respiratory failure). They should also monitor and encourage individual providers as they adopt these definitions in their documentation and escalate noncompliance with these definitions to physician advisors, compliance officers, or medical staff leadership.

While one physician may not use ASPEN, or the Academy of Nutrition and Dietetics criteria, to define and diagnose malnutrition, I challenge readers to find any support for pre-albumin or albumin as a current clinical indicator for malnutrition, or more authoritative criteria than that of the nation’s premier association of dieticians and nutritional support teams.

Multiple choice queries

AHIMA appears to have changed the language for multiple choice queries with this practice brief, especially when clinical validity is an issue (something it supported in its 2013 Guidelines for Compliant Query Practices, jointly authored with ACDIS). In its recent policy brief, AHIMA offered an example for validating documented sepsis without apparent clinical indicators, they offered the following multiple choice options:

• Sepsis was confirmed
• Sepsis was ruled out
• Sepsis was without clinical significance
• Unable to determine
• Other ______________

Given that this is AHIMA’s query format, we’re obligated to consider it; however, this does cause some difficulties. What can a coder do with “sepsis was without clinical significance” or “unable to determine,” if that’s the option the provider selects? If “sepsis was without clinical significance” is selected, do we not code it with the belief that the documented condition doesn’t qualify as an additional diagnosis as defined in the ICD-10-CM guidelines? How many of us have run into physicians who document “unable to determine” as a way of avoiding the question?

I believe that if any of these two options are chosen, then the record should be escalated to a physician advisor or coding manager who implements the facility’s policy of coding the documented diagnosis without defendable clinical indicators.

Editor’s Note: This article originally appeared in JustCoding. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at jkennedy@cdimd.com. Opinions expressed are that of the author and do not represent HCPro or ACDIS.