Problem Lists, Leading Queries Top CDI Concerns

Ethical and compliant physician queries is the heart of clinical documentation improvement (CDI), and William Haik, MD, FACCP, CDIP, director of DRG Review, is concerned about an emerging ethical issue in the profession.

“The biggest problem is the problem list as best I can tell, and that’s going to be addressed in a soon-to-be future Practice Brief, using problem lists effectively,” Haik says of the electronic health record (EHR) feature that lists a patient’s most pressing ongoing conditions, which may or may not be relevant during a given inpatient or outpatient encounter.

Haik says that as Medicare Advantage relies on risk adjustment systems to reimburse hospitals and physicians, reporting illnesses from a patient’s problem list—based on their presence on the problem list—is becoming an ethical issue in CDI.

“They’re diligent and sometimes overly diligent reporting these additional diagnoses that are no longer relevant—not relevant to the current encounter. It can boost the severity of that patient, sometimes inappropriately, if the condition is no longer there,” Haik says. “Risk adjustment auditors look at these things. That becomes a difficult problem. The problem list is often the problem.”

Ethics Takes Center Stage at CDI Summit

Haik will be co-presenting at AHIMA’s CDI Summit with Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, independent consultant, on topics including an upcoming CDI Practice Brief AHIMA is producing with the Association of Clinical Documentation Improvement Specialists (ACDIS).

Bryant will lead the discussion on ethics in CDI, which will address how CDI specialists can avoid writing queries with non-leading language through the use of query templates.

“There have been some interesting issues surrounding CDI and HCCs of late,” Bryant says. “Due to the direct linkage of the clinical documentation to the coding and to reimbursement, there needs to be greater oversight of technology that is used in both CDI and coding, so we achieve compliant querying.”

To avoid this in CDI practice she says there really must be a quality assurance or review process for CDI, similar to that of coding, with auditing and monitoring. “Random and focused checking and reviewing of the queries and the query process should be in place within a CDI program or department,” Bryant adds.

AHIMA’s CDI Summit will be held in Chicago, IL this year July 14 – 15. Bryant and Haik’s session, “CDI Compliance, Ethics, and the Practice Brief,” will be the first educational session on Sunday, July 14. For more information, visit http://www.ahima.org/events/2019cdisummit.
Mary Butler is associate editor at Journal of AHIMA.

2 Comments

  1. Our CDI team is writing leading queries as their query often includes only the desired answer, “clinically undetermined and other (please explain).” I have written AHIMA in the past and the person at AHIMA agreed with me that only having one viable option can be considered leading and we are getting denials from third party payers. Attempts to address this with the CDI director for our multi-hospital and clinic healthcare system has been met with defensiveness and hostility. Her justification in only having one option (in addition to clinically undetermined and other) is the sentence in the AHIMA Guidelines for Achieving a Compliant Query Practice (2016 Update) on page 2 that states “Multiple choice query formats should include clinically significant and reasonable options as supported by clinical indicators in the health record, recognizing that there may be only ONE reasonable option.” Our CDI personnel are nurses, none of whom have a coding background as far as I know and they are often questioning and arguing with the coders even though they have no experience in this area. Sepsis is a popular item to query for and I wish they could comprehend that not everyone who has a UTI, pneumonia etc. with an elevated white count and tachycardia has sepsis. This has also led to clinical and coding denials. Also, on most of the pneumonia charts I have seen they ask the physician if he/she “cannot rule out gram negative pneumonia.” Of course they usually can’t so it’s considered an uncertain diagnosis at discharge. Unless a sputum culture is positive for an organism then they really cannot rule out any type of pneumonia-viral, staph, e.coli etc. and the CDI personnel should not be asking this question without a positive sputum culture for a specific organism. As nurses, I believe they should understand that most sputum cultures only grow oropharyngeal flora only. To ask the gram negative pneumonia question (and getting the higher DRG when it of course can’t be ruled out) is possibly opening up a Pandora’s box for auditors that would likely result in negative consequences.

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  2. Hi Mary –
    Thanks for bringing up your experiences, you bring up a lot of good points. Full disclosure: I’m a CCDS with a RN background.

    I agree ethics and compliance should be foremost in the minds of both CDI and coding professionals. I’m not sure about your situation (of course, would need specifics) but I’d think that if you’ve not gotten resolution discussing this with the CDI director, perhaps it’s worth discussing with your coding or denials director, or perhaps your compliance officer?

    I can certainly see that there may be CDI or provider issues (like query compliance, query exhaustion and diagnosis creep) that may be producing what you describe. But I also think there’s a potential for some misunderstandings about the skill sets and expectations of the various job roles. I can say from my own experience that I have to write a lot of sepsis queries these days, and if I saw solid clinical indicators for a gram neg PNA, I’d definitely query it. This is 100% expected – any CDI would be held accountable if they failed to act on solid indicators. But I also openly discuss with my coder where I’m finding the indicators, which ones are borderline or less important and which ones are pathognomonic. I think she then better understands why I expect that pulmonologist to restate the “unable to rule out” condition, and keep that asp PNA DRG, and why I expect that beautifully documented sepsis chart to be ruled out on the retro query. Sometimes the provider proves me wrong. And sometimes my coder corrects me when I miss coding something important.
    This is truly collaborative work, and I love that about it.

    But that doesn’t mean it’s always smooth sailing. As my director says: “the fight is real”, and with multiple departments, things can get messy. But I think that by always coming back to a habit of collaboration, and respect for each other’s skill sets and expertise, we can best analyze how these issues arise and interact, and get at the root problems. I think we can all fight together for well thought-out care, with resulting well-documented charts, and well-coded cases.

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