by Christine Donnamiller, RN, ACDIS-Approved CDI Apprentice for ACDIS CDI Blog
I know it’s not easy.
I see you documenting early in the morning, afternoon, and late in the evening. Somewhere in the middle you are holding that patient’s heart by speaking your words to him, speaking with the dying woman’s daughter, setting up home oxygen, putting in a central line while ordering a Cardizem drip for the patient in the next room—the good deeds and duties never end.
Then you have to document, or answer that query. I imagine you’re feeling “alert fatigue,” and I want you to know that what you are doing is noticed and admired. I know I ask you for more, more documentation. And then more questions, clinical decisions and actions in our world, when captured correctly, will equal financial results. We need to follow the money to survive in this business.
Documentation and accurate coding matter in terms of statutory and regulatory necessity for submission of claims. Establishing diagnoses that are clinically supported will impact quality measures, quality metrics, patient risk assessment, mortality rates, and reimbursement. Clinically unsupported diagnoses often result in denials, which wastes time and resources. Clinical validation queries are part of the process that will help bullet-proof the code set for the final bill, preventing denials.
Our goal as CDI professionals is to ensure the integrity of the chart by ethically and clinically upholding the record through effective communication with the providers via verbal communication, email blurbs, and queries. As your CDI team, we interpret your clinical documentation into ICD-10 codes, based on the Official Guidelines for Coding and Reporting.
In my nearly three years as a CDI specialist, I have found some astonishing differences that one undocumented word may make in the code set. We are your second pair of eyes and here to help you. Our patients deserve a true account of the care they receive, the irrefutable truth of the record is what we need from your documentation. And we strive to get it right the first time. I would rather send you a clinical validation query than perform a denial review and tell my boss that I can’t clinically validate the diagnosis.
This education is not to offer clinical insight, rather to share the purpose of a clinical validation query. With a recent United Healthcare sepsis denial fresh under our feet, running alongside of a sepsis case that cannot be supported clinically, I have chosen sepsis examples for the purpose of discussing clinical validation.
Let’s start by looking at the denial I referenced.
Denial for an United Healthcare admission, March 2020
United Healthcare no longer will use our sepsis definition; they will only use the Sepsis-3 (sepsis with associated acute organ dysfunction). See the foreword from the denial.
United Healthcare will implement clinical guidelines that utilize Sepsis-3. The guidelines will be used as part of United Healthcare’s claim reviews to clinically validate that sepsis was present. Hospital DRG payments will be adjusted if United Healthcare determines, after reviewing the member’s medical record and Sepsis-3, that sepsis was not present. We will also use the Surviving Sepsis Campaign International Guidelines for Management of Sepsis and Septic Shock (2016) to promote good health outcomes for our members.
Let’s look at the admission for which they denied the sepsis diagnosis. The admission is from March 27-29, 2020:
- Sepsis WITH Acute on chronic hypercapnic, hypoxic respiratory failure
- Acute on chronic Systolic CHF
- Lobar pneumonia
- Atrial fibrillation
- Chronic obstructive pulmonary disease – AE dependence on O2 for obstructive sleep apnea
- Ischemic cardiomyopathy
- Other long-term drug therapy
- Long-term use of anticoagulants
- C-reactive protein: 185.6
- Non-diabetic blood sugars: 139 131 150
- Respiratory rate: 28, 41, 52; 87% BIPAP
- Mean arterial pressure: 65 96/51 68 93/50
- Temperature: 96.9 96.2
- Sepsis risk: 10.4
- Sequential Organ Failure Assessment (SOFA) score: 4 points
- Patient 34 internal normalized ratio 3.45 (possible coagulopathy defect associated with Sepsis) no diagnosis documented
- Heart rate: 109, 118 easily explained by atrial fib
- White blood cell count: 15.7; Left shift may be explained by the pneumonia
Here’s what I takeaway from this case. First, there are three possible sepsis-associated dysfunction diagnoses listed (they don’t have to be in organ failure to be diagnosed with sepsis). The three listed are acute respiratory failure, acute systolic congestive heart failure, and possible undocumented coagulation defect.
If you (the physician) mean sepsis with associated acute respiratory failure, then you must document the association. “With” does not equal association in the Official Guidelines. The clinical indicators are present, but the documentation is not. United Healthcare and I do not know if the physician meant sepsis with associated acute respiratory failure when they documented sepsis “with” acute respiratory failure. Sepsis has been removed by the payer, and we are not being paid for the diagnosis of sepsis.
For more information on coding and reporting sepsis associated organ dysfunction, see p. 25 in the fiscal year 2020 ICD-10-CM Official Guidelines for Coding and Reporting.
Sepsis clinical validation
Let’s take a look at a sepsis validation query we sent to a provider in June 2020 to clarify sepsis with diverticulitis of the intestine. According to the documentation, sepsis cannot be clinically supported and the one possible clinical indicator (white blood cell count of 14.1) may be easily explained by the diverticulitis of intestine. The provider, however, had documented sepsis in the record, so the CDI team sent the following query:
We are seeking some clarification to have a complete and accurate medical record. Please respond to this query immediately and document clarification within the patient’s medical record. Please also know that this message will become a part of this patient’s legal medical record.
The clinical findings below are documented within the patient’s medical record:
- Admission 5/30-6/1/2020
- White blood cell count: 14.1, 9.9, 7.9
- Lactic acid: 1.6
- Bilirubin: 0.2
- Non-diabetic blood sugar: < 140 Heart rate: >90 noted 1 time in the record – 100
- Respiratory rate: 22 noted 1 time in the record
- Based on your medical judgement please clarify the diagnosis of sepsis.
Is the diagnosis:
- Ruled out
- Unable to be determined
- Other (please specify)
We really want to get the documentation right the first time, which will save a lot of people work, including you.
The CDI team wants to improve our processes by simplifying what is needed from the physicians, and assist you with documenting the veracity of the record, as we transcribe your documentation into ICD-10 codes.
When I went to nursing school, they told us if it isn’t documented, it didn’t happen. Now, if it isn’t documented right, the hospital doesn’t get paid. As many have said, we need to learn to “think in ink.”
It is my belief that coding is bolstered by clearly documenting the manifestations and clinical indicators in a fashion that leaves no questions left behind. When the documentation provides this level of detail, it will be bullet proof to denials.