We document to detail the patient encounter for ourselves and other clinicians. The fact that coders, auditors, and lawyers use the same medical record is mostly an annoyance to healthcare providers (HCPs). Let me use clinical examples to demonstrate the difference precision of language makes. For instance:
“10 units of blood, persistently low blood pressure, need for vasopressors” does NOT equate to “hemorrhagic shock”
“Severe sepsis secondary to aspiration pneumonia, with acute hypoxic respiratory failure, in a patient with functional quadriplegia” conveys a different message than, “Pneumonia; hypoxemia; NH patient.”
Clinical Documentation Integrity is NOT just about documenting for the bean-counters; it is our method of communicating what we are seeing and thinking about the patient and their data so that the patient looks as sick in the medical record as he does in real life. A CDI Specialist (CDIS) reviews the medical record to see if there are opportunities for clarification so the HCP gets credit for diagnosing or managing those conditions. A CDI physician advisor supports the CDISs functioning as a peer-to-peer advisor.
I believe INTEGRITY is the operative word in the phrase. We don’t want to wildly speculate or claim credit for conditions which weren’t present. This is not about making the patient appear sicker or getting paid more. It is about accurately representing the severity of illness and risk of mortality of each patient. Integrity reinforces that the HCP should “Tell the Truth.”
CDISs are not allowed to LEAD the HCP. That is, only the HCP may diagnose a patient she is taking care of, so even a CDIS with clinical experience may not formally make a diagnosis. So she isn’t permitted to smack a doc upside the head and say, “Just write ‘encephalopathy’!”
Here are acceptable reasons to generate a query:
Conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent documentation. Let me add “Dragon gobbledygook” as an additional reason now.
Clinical indicators, diagnostic evaluation, medical treatment, or a procedure which seem to suggest a definitive diagnosis which is not documented in a codable format
A diagnosis which does not seem to have clinical validation
Question regarding present on admission indicator assignment
The CDIS should either be giving information and asking if there is a corresponding diagnosis, or giving multiple choices, including some variation on ‘clinically undetermined’ and ‘other.’ Rather than defaulting on one of these because it is easiest, the HCP should really consider the query and try to answer. If they don’t understand what is being asked, it is permissible to ask questions for clarification.
Codes must be supported by documentation by the HCP. An inpatient coder may not infer “I50.31, Acute diastolic heart failure” from the documentation of “fluid overload.” By the same token, if the HCP selects his own code for his professional bill, the documentation must still support it. Documentation of “sinusitis” in the assessment and plan section, cannot be coded with “J01.01, Acute recurrent maxillary sinusitis.”
Once the codes are selected, they are submitted for “credit”, not only for reimbursement, but for quality metrics. They define the DRG, the RW, the SOI/ROM, and affect the denominator (expected) of risk-adjusted quality metrics, for example, the risk-adjusted mortality index.
If you don’t document well, such that your code set is incomplete or your codes are unspecified, your calculated metrics may look suboptimal. You will not be credited with providing quality care.
ICD-9 looked like a coding system designed by lawyers; ICD-10 looks like one designed by scientists. There are WAY many more diagnosis codes which gives you the ability to more specifically detail conditions. There are about 72,000 ICD- 10-CM diagnosis codes.
People disparage the external causes codes (you know, struck by duck on burning water skis), but simply put, they are available to you, not MANDATORY. You might be able to appreciate the utility of being able to tease out pedestrian vs. car collisions or falls associated with Y93.C2, Activity, hand-held interactive electronic device. Epidemiology and research are the real beneficiaries of external cause codes.
ICD- 10-PCS has the coder assign procedure codes for inpatient procedures in a novel way. What was accomplished is detailed. If a patient was intended to have a Whipple procedure, but just got closed back up without the procedure, the root operation would be “Inspection.” Operations in ICD-9 which might or might not have had a component procedure can now be teased apart (e.g., nephrectomy in ICD-9 – can now separate out the resection of the kidney and the resection of the ureter). Originally with approximately 80,000 codes, each year sees the addition of around new codes, to reflect novel procedures.