Written By: Rachel Mack, RN, MSN, CCDS, CDIP, CCS
Clinical Program Manager
We all tend to have a number of “firsts” we never forget when it comes to our CDI careers:
- First positive interaction with a physician
- First educational session with a physician group – and it goes well
- First coder interaction where you have a light-bulb Coding Clinic moment
- First time you felt as though you truly impacted patient care
My first example of impacting patient care is when I saw a patient with a slew of clinical indicators for malnutrition diagnosis (including significant weight loss, decreased PO intake, a pressure ulcer, and a BMI of 12). I did not yet see an order for a dietitian evaluation, and the patient had been in the hospital for several days. I took a risk and sent the query anyway; the next day the physician I sent the query to put in an RD order. That dietitian went on to document that the patient met criteria for severe protein-calorie malnutrition. I thought, “wow, I helped do that.”
But another instance I’ll never forget is opening a denial email from Coding and seeing that an insurance company was denying all three MCCs for one case.
….three MCCs. No wonder the Coding department had reached out for CDI help!
It’s commonplace for insurance companies to deny whatever they can, whether clinically sound or not. But all three MCCs? I had to dive in and take a look. After review, I discovered that they were partially correct: one diagnosis was incorrectly coded (acute respiratory failure final coded, but was part of a previous visit only), and in our defense letter I acknowledged that yes, we should remove it from the final bill. However, the other two diagnoses – metabolic encephalopathy and septic shock – were above and beyond clinically sound. The patient was confused with a GCS score of 11 that improved to 15 by discharge and was treated with a head CT, sitter, and safety restraints. And the patient was clearly in septic shock and required Levophed s/p aggressive fluid resuscitation to improve their blood pressure.
So what can CDI specialists do to make sure records are as safe as possible from denials?
Here at Iodine Software we have a few best-practice suggestions:
- Query consistently for clarification of conditions when the clinical indicators are present but there is no associated documentation (or vice versa when it comes to clinical validation). When we do this consistently, we help teach our providers to consistently document with a higher level of specificity.
- Query consistently regardless of the financial impact to the record. Only querying for a first CC or MCC is no longer acceptable practice in CDI. If we only query for conditions when they impact the DRG, we are doing our physicians and providers a disservice. This behavior has potential positive downstream effects on quality metrics beyond the scope of typical CDI programs.
- Query consistently to determine present-on-admission (POA) status of conditions. It’s very easy for us (as clinicians reading the record concurrently) to make assumptions and assume that the coder will realize something is POA.
- Query consistently if a condition or conditions are documented in such a way that they are unclear, inconsistent, vague, or non-specific. If a condition is not clear for us reviewing a record concurrently, it will likely not be clear for the coder and is at risk for not final coding or requiring a retro query.
I don’t think we should query simply out of fear of denials. That’s no way to live or to work. But we do have to be aware of the healthcare climate of today. Hospitals are depending on us to prevent denials as much as possible – and confirming accurate documentation of diagnoses irrespective of impact is our responsibility.
I hope this spurs some critical thinking for CDI specialists. At the least, I hope next time you hear someone say “Yeah, I’m not going to query, this record is maxed out,” you might encourage them to think again.