Strategies for Unsupported Diagnoses - ACDIS · – Patient given morphine 4 mg IVP with CP improving to 2/10. Oxygen ... • Code assignment and clinical criteria have been added

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Patti Nemeth, BSN, RN, CCDS, CCS, AHIMA‐Approved ICD‐10‐CM/PCS TrainerCDI Manager

Susan Haley, RHIT, CCS, CRC, CCDS, AHIMA‐Approved ICD‐10‐CM/PCS TrainerCDI Senior Consultant

The Claro Group, Chicago, IL

Compliant Strategies for Unsupported Diagnoses

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Define when a condition meets UHDDS guidelines for reporting as an additional diagnosis

– Name common conditions that are targeted due to lack of clinical support in the record

– List three strategies for confirming or ruling out unsupported diagnoses and how CDI can impact each of these

– Describe how the reporting of unsupported diagnoses will impact the outcomes of the audit denial and appeal process and meeting criteria for medical necessity

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2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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Polling Question #1

• Is your facility doing confirmation/validation queries for documented conditions that lack clinical support in the medical record?

– Yes

– No

– I don’t know

– Not applicable

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Clinical Scenario

• 69‐year‐old male presents to ED with chest pain 8/10 and SOB

– VS: T 98.6 oral, BP 170/98, HR 88, RR 16; SpO2 97% on RA.

– Patient placed on 2L NC oxygen, given NTG SL x3 with some relief. States CP 4/10. Still c/o SOB, O2 Sat 98% on 2L NC.

– Patient given morphine 4 mg IVP with CP improving to 2/10. Oxygen increased to 4L NC for patient comfort.

• ED provider documents “Admit to telemetry – CP r/o MI, acute respiratory failure”

• These diagnoses are carried into the H/P and first PN

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Principal Diagnosis

• Principal diagnosis:

– Defined by the Uniform Hospital Discharge Data Set (UHDDS) as “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care”

– The circumstances of admission, the diagnostic approach, and the treatment rendered factor into the selection of the principal diagnosis


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Secondary Diagnoses

• These are conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay

• Other diagnoses as additional conditions that affect patient care in terms of requiring any of the following:– Clinical evaluation

– Therapeutic treatment

– Diagnostic procedures

– Extended length of stay

– Increased nursing care and/or monitoring

• Only ONE of the above is necessary for a condition to be reported—as you can see, the condition does not necessarily have to be “treated”

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AHIMA’s 2013 Practice Brief

• The practice brief states:

– 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.

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AHIMA’s 2016 Practice Brief

• Clinical validation: The next level of CDI—this brief provides guidance on a clinical validation process when there is lack of support in the medical record to support a documented condition

• The generation of a query should be considered when the health record documentation:

– Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis

– Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure

– Provides a diagnosis without underlying clinical validation


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2017 Changes to Official Coding Guidelines

• Code assignment and clinical criteria have been added as follows:

– The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

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Standards of Ethical Coding

• AHIMA Standards of Ethical Coding– “Assign and report only the codes and data that are clearly and

consistently supported by health record documentation in accordance with applicable code set and abstraction conventions, rules and guidelines”

– “Query provider (physician or other qualified healthcare practitioner) for clarification and additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g., present on admission indicator)”

– Concurrent queries, initiated “real‐time,” encourage more timely, accurate, and reliable responses

– “The query should never indicate that a particular response would favorably affect reimbursement or quality reporting”

Source: AHIMA. "Managing an Effective Query Process." Journal of AHIMA 79, No. 10 (October 2008): 83–88

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Statement of Work for the Recovery Audit Program

• DRG validation vs. clinical validation– DRG validation is the process of reviewing physician

documentation and determining whether the correct codes and sequencing were applied to the billing of the claim. This type of review shall be performed by a certified coder.

– Clinical validation is a separate process, which involves a clinical review of the case to see whether the patient truly possesses the conditions that were documented.

• Clinical validation is beyond the scope of DRG (coding) validation and the skills of a certified coder

• This type of review can only be performed by a clinician, or may be performed by a clinician with approved coding credentials

Source: https://www.cms.gov/Research‐Statistics‐Data‐and‐Systems/Monitoring‐Programs/Recovery‐Audit‐Program/Downloads/090111RACFinSOW.pdf


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Polling Question #2

• What is the most common confirmation query written by your CDS?

– Sepsis

– Respiratory failure

– Malnutrition

– Acute renal failure

– Other/not applicable

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The CDI Role in Unsupported Documented Conditions/Diagnoses

• Note the documented conditions

• Recognize there is lack of clinical support in the current documentation

• Obtain clinical validation from the provider through a compliant query

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Query Definition

• “A query is defined as a question posed to a provider to obtain additional, clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes in the patient’s health record”– Source: AHIMA. "Managing an Effective Query Process." Journal of

AHIMA 79, No. 10 (October 2008): 83–88.

• “The desired outcome from a query is an update of the health record to better reflect the practitioner’s intent and clinical thought processes, documented in a manner that supports accurate code assignment”– Source: AHIMA. “Guidelines for Achieving a Compliant Query

Practice.” Journal of AHIMA 84, No. 2 (February 2013): 50–53.


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When to Query

• The generation of a query should be considered when the health record documentation:

– Provides a diagnosis without underlying clinical validation

– Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent

– Describes, or is associated with, clinical indicators without a definitive relationship to an underlying diagnosis

– Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure

– Is unclear regarding present on admission indicator assignment

Source: AHIMA. “Guidelines for Achieving a Compliant Query Practice.” Journal of AHIMA 84, No. 2 (February 2013): 50–53.

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Confirmation Queries

• RAC and other outside auditors are now denying claims citing lack of clinical support for certain conditions. These are often conditions that provide an MCC and indicate a much higher acuity. Common conditions targeted for lack of clinical support include:– Sepsis

– Respiratory failure

– Severe malnutrition

• The February 2013 AHIMA practice brief states: “When a practitioner documents a diagnosis that does not appear to be supported by the clinical indicators in the record, it is advised that a query be generated to address the conflict or that the conflict be addressed through the facility’s escalation policy.”

• CDI and HIM staff are now being faced with needing to clarify documented conditions with the providers. This must be done without appearing to question the provider’s medical judgment, but simply asking for additional documented clinical support for a specific condition, or to determine whether the condition was ruled out.

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Confirmation Queries—Considerations

• Physicians can make clinical diagnoses based on criteria outside the recognized standard criteria; however, this medical decision‐making needs to be documented to provide the clinical support– Encourage the physician to “think in ink”

– Example: Pneumonia is often diagnosed in the absence of x‐ray findings, especially in the patient who is also dehydrated

• On admission, clinical indicators may support a condition that after study, and the patient’s response to treatment, has likely been ruled out—however, the condition is not documented as such– Example: Sepsis documented on admission; next day, patient is

changed to PO antibiotics and discharged


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Confirmed or Ruled‐Out Query

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Common Conditions Targeted Due to Lack of Clinical Support

• Acute respiratory failure

• Sepsis

• Severe malnutrition

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Acute Respiratory Failure

• Acute respiratory failure is often targeted in the following situations:

– When it is the only MCC on the record

– When the documentation indicates the patient was intubated only for airway protection

– In the postoperative period (overnight vent after OR and then extubated)


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Acute Respiratory Failure Criteria

• ABG values – any one of the following:1

– pO2 < 60 or SpO2 (pulse oximetry) < 91% on RA

– pCO2 > 50 and pH < 7.35– P/F ratio (pO2/FiO2) < 300– pO2 decrease or pCO2

increase by 10 mmHg from baseline if known

• Supplemental O2 requirement of 40% or more1

(1) Source: ACP Hospitalist Oct/Nov 2013

• When also present with the criteria listed on the left, symptoms that support acute respiratory failure may include:– Tachypnea, SOB, dyspnea– Pallor or cyanosis– Anxiety or restlessness– Use of accessory muscles– Retractions (grunting in

newborns)– Unable to speak in

complete sentences

• Intubation not required

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Other Considerations

• Patients who are, or remain, intubated “for airway protection” are not considered to be in respiratory failure.– Reference: Coding Clinic, Third Quarter 2012 p. 21

• Patients who remain on mechanical ventilation postoperatively are not necessarily in respiratory failure.– Continued mechanical ventilation for up to 48 hours postoperatively is

considered a normal part of recovery

• If respiratory failure is documented, especially during the immediate 48 hours postoperatively, additional documentation is needed to support this diagnosis. This may include:– Unsuccessful attempt at weaning

– Requiring higher pressures, or oxygen concentration, than would be expected

– No spontaneous respiratory effort

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Acute Respiratory Failure: What to Look For in the Medical Record

• EMS and ED documentation

• Ancillary staff notes – Respiratory therapy

– Nursing notes

• Review the circumstances around the intubation– What was the work of breathing?

– What was the oxygen level?

• Review the ventilator setting and ABGs– What are the vent settings?

– Are the vent settings increasing?

– What are the ABG results?

– Is the patient sedated or not sedated?

– Is the patient breathing over the vent?

• For postoperative patients:– Was the mechanical ventilation planned?

– Was the patient re‐intubated in the PACU?


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Respiratory Failure Clinical Scenario

• ED triage note: SOB, cough, weakness; more SOB than usual; patient stated she had to increase her oxygen level from 2 to 4L NC

• PMH: COPD, HTN, home O2 2L ATC • VS: T 98.3 oral, BP 153/61, HR 65, RR 22; sats 90%–92% 4L NC• Treatment in ED:

– Solumedrol 125 mg IVP

– O2 4L NC

– Duonebs x3 20 minutes apart

– CXR: Hyperinflation suggestive of COPD, minimal basilar atelectasis, no infiltrate or effusion seen

• ED provider: “Admit to IP for AECOPD and acute on chronic respiratory failure”

• H/P: Acute hypoxic respiratory failure/COPD exacerbation

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Confirmation Query for Acute Respiratory Failure

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Sepsis

• The term “sepsis” must be documented, and there must be an “infection”

• Auditors are generally looking for the standard SIRS criteria

• This is a targeted dx for short LOS


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Sepsis: What to Look For in the Medical Record

• Complete and accurate documentation is essential when assigning this PDx

– Look at the entire clinical picture

– Consider treatment rendered and patient’s response to treatment

– Consider length of stay and orders at the time of discharge

• A confirmation/validation query may be needed if sepsis is documented and there is a lack of clinical support in the medical record

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Sepsis: Where to Look in the Medical Record

• ED notes

– Vital signs and labs to support SIRS criteria

– Medications, fluid boluses, antipyretics

• HP and PN for consistency in documentation

• Consults such as infectious disease

• Pharmacist notes

• MAR: Changes to or discontinuation of antibiotics

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Sepsis Clinical Scenario

• Patient presents to ED with chief complaint of weakness and subjective fever. VS on arrival: T 99.6 oral, BP 130/78, HR 89, RR 18; SpO2 96% on RA. Labs include WBC 13.6, UA +LE, URC sent. Patient started on Rocephin 1 mg IVPB qDay.

• ED note 6‐25: “Admit to gen med—sepsis due to UTI.”

• H&P: “UTI, sepsis.”

• PN 6‐27: “UTI, SIRS 1/4. Urine Cx > 100,000 E. coli UTI. DC patient to home with Rx for Bactrim po.”


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Example Query for Sepsis Confirmation

• Noted documentation of:– ED note 6‐25: “Admit to gen med—sepsis due to UTI.”

• VS: T 99.6 oral, BP 130/78, HR 89, RR 18; SpO2 96% on RA

• Labs: WBC 13.6, UA +LE, URC sent

• Rocephin 1 mg IVPB qDay x 2 doses

– H&P: “UTI, sepsis.”

– PN 6‐27: “UTI, SIRS 1/4. Urine Cx > 100,000 E. coli UTI. DC patient to home with Rx for Bactrim po.”

• Please specify in the progress notes which, if any, of the following is the most likely etiology of the above symptoms and treatment rendered:– Sepsis was present on admission and now resolved

– After study, sepsis is ruled out

– Localized infection (UTI only)

– Other, please specify

– Unable to determine

• Use of terms such as suspected, probable, and possible (associated with a specific diagnosis that is being evaluated, monitored, or treated as if it exists) are acceptable and can be coded in the inpatient setting.

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Severe Malnutrition

• Severe malnutrition is often the target in the following situations:

– The payer questions the severity of the condition

– It is the only MCC on the record

– The diagnosis is documented but not supported by clinical validation

– There is a documentation conflict or inconsistently documented diagnosis

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Severe Malnutrition Criteria and What to Look For

• ASPEN criteria and other clinical indicators for severe malnutrition:– Comorbid conditions

– Energy intake and current method of feeding

– Unintentional weight loss, amount and % body weight

– Laboratory markers such as albumin, prealbumin, total lymphocyte count (other criteria)

– Exam findings such as muscle wasting or atrophy, loss of fat stores, edema, cachexia

– Reduced grip strength (measurable reduced)

Note: ASPEN criteria no longer recognizes albumin and prealbumin as criteria. These may be used if it’s the facility’s practice to do so.


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Severe Malnutrition: Where to Look in the Medical Record

• H&P

• Laboratory tests

• Consultations by various disciplines

• Imaging tests

• OR reports

• Nursing notes

• Nutritional consult

• Wound therapy consults

• Speech‐language pathology notes

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Malnutrition Clinical Scenario

• 85‐year‐old with history of lung cancer s/p lobectomy, chemo and radiation, recent CVA, dysphagia, cachexia

• Nurse’s notes: Weight 120 lbs, height 5’7”, BMI 18.6 with 25‐pound weight loss over last 3 months

• Speech therapy: Dysphagia, NPO status continued, not judged to be safe for any PO intake

• Nutritional consult: Body fat depletion, severe muscle loss, NJ placed, malnutrition

• PT: Measurable grip strength reduction, having difficulty with therapies

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Malnutrition Confirmation Query


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Impact on Medical Necessity and the Audit Appeal and Denial Process

• Severity of illness – Symptoms

– Other clinical indicators

– Think in ink

• Intensity of service – What are we doing for the patient?

– Does it support an inpatient admission?

– We should be considering: Is it documented appropriately?

• Focused on adequate documentation in the record BEFORE the bill goes out and then is denied for lack of clinical support

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Impact on Medical Necessity and the Audit Appeal and Denial Process

• Proactive vs. reactive: It is about being proactive and avoiding the denials rather than needing to focus on appeals

• It’s important that CDI is represented in the appeals process

• CDI can support and recognize the clinical indicators and variations that present opportunities

• Clinical validation is a function of CDI, not coding, but there should be COLLABORATION prior to final coding

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Thank you. Questions?

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.


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Strategies for Unsupported Diagnoses - ACDIS · – Patient given morphine 4 mg IVP with CP improving to 2/10. Oxygen ... • Code assignment and clinical criteria have been added

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