Chart Conundrums: Desperately Seeking Clinical Validation

By Angie Dibble, RHIT for For The Record

Sepsis, encephalopathy, malnutrition, and acute renal failure are examples of diagnoses that often prove vexing for coders and clinical documentation improvement (CDI) specialists.

What if the sepsis diagnosis is based on “technically meets sepsis criteria” because a patient with a urinary tract infection has an elevated white blood cell count and a fever? On paper, the patient has two out of four criteria for sepsis, right? What if the provider documents severe malnutrition in a patient with a healthy body mass index (BMI) and an albumin of 1.7? A coder or a CDI specialist is likely to cringe when they see these scenarios cross their screens.

Where is the line between questioning provider judgment and clinical validation? How do payer audits and denials factor into the equation? Do payers deny every case with a severe malnutrition coded if the patient does not have a BMI less than 16?

These scenarios are not uncommon. In these situations, where do coders and CDI specialists turn for advice? Who makes the call, CDI or coding? What if those departments disagree?

The Final Call

The cardinal rule taught in all coding and CDI programs is that the provider is legally responsible for establishing the diagnosis. The provider can rule in/out a diagnosis, state it as confirmed, probable, suspected, etc. Does it state in the coding guidelines that coders or CDI specialists can rule in/out a diagnosis or determine whether the encounter was supposed to be documented or exists?

The 2017 ICD-10-CM Official Guidelines for Coding and Reporting state, “The assignment of the diagnosis code is based upon the provider’s diagnostic statement that the condition exists. The provider’s statement that a condition exists is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

Does this guideline eliminate the need for a CDI/coding review or a query for clinical support for a diagnosis? Coders and CDI specialists should look at the guideline in the same way they look at a diagnosis for specificity. The guideline states, “The code assignment is not based on clinical criteria used by the provider to establish the diagnosis.” If the provider documents a condition, then he or she has rendered a clinical opinion as the person legally responsible for establishing the diagnosis. In other words, diagnosis XYZ is the final answer for coding and reporting.

Coders are not responsible for determining what version of sepsis criteria is the best one to “check up” on the clinical accuracy of the provider’s diagnosis and determine whether it should be coded. Coders have the responsibility to code the diagnosis legally established and documented.

On the other hand, some may believe that CDI specialists can determine whether a diagnosis documented by the provider should be coded or not coded based on clinical criteria. It may be assumed that CDI specialists have more clinical understanding of the record in addition to the coding knowledge to determine concurrently whether the record should be queried for specificity or coded.

However, the question of “should it be coded” can create a quandary. Neither a CDI specialist nor a coder can determine that a legally documented diagnosis by the provider should not be coded because the clinical criteria may be too weak for a payer and result in a denial.

But what about documentation that does not appear clinically valid?

Time to Query

Coders and CDI specialists can establish the clinical validity of a diagnosis with providers by doing what they do best: query, specify, educate, and listen.

For CDI specialists, the best option for tackling a diagnosis that is not clinically well supported is to have a face-to-face meeting with the provider whenever possible. If the opportunity presents itself, CDI specialists should meet as many providers as possible in orientation to briefly explain the role of CDI and the purpose of queries. It’s an ideal situation to establish that a clinical support query may happen occasionally and to not consider it to be questioning the provider’s medical decision making.

Will this advice be heeded when a CDI specialist writes a potentially annoying query titled Clinical Congruence? Maybe not. Nevertheless, CDI specialists can take comfort in knowing that it’s been established that queries are used only when necessary and never in an attempt to point out an error in clinical judgment.

A Clinical Congruence query states the diagnosis in question and where it was documented. Also, it lists further relevant information in the record such as lab results, imaging study results, and consult documentation and where they were found.

The query politely asks the provider to provide the clinical indicators that support the diagnosis in question. This is the provider’s opportunity to make his or her case for the diagnosis or, after considering the relevant clinical information presented from the record, determine that an alternative diagnosis may provide a clearer clinical picture of the patient.

Lessons Learned

The question of clinical validity can be established or considered by providers through a concise query that requests elaboration on the diagnosis. The question is not whether diagnoses that appear unsupported should be coded. Rather, the question is how coders and CDI specialists can communicate the need for additional clinical support for the diagnosis or help providers determine whether the diagnosis documented truly represents the clinical picture they are trying to establish. Whenever possible, CDI specialists should provide criteria that the medical community recognizes as being clinically valid.

What if the provider chooses to document a diagnosis that the CDI specialist deems to be not clinically valid? Remember, the Official Coding Guidelines state, “The assignment of the diagnosis code is based upon the provider’s diagnostic statement that the condition exists. The provider’s statement that a condition exists is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

Considering that assigning the code is directed in the guidelines, it removes a great deal of pressure from a CDI specialist or a coder. It is not up to these HIM professionals to determine whether a code should be reported. Instead, they must determine when and how to query the provider for the clinical support for the diagnosis that is mandated by the official coding guidelines.

Once CDI specialists and coders realize where the boundary lines lie between who is legally responsible to determine the diagnosis, who is responsible for clarifying the diagnosis when necessary, and when HIM professionals are directed and supported by official guidelines to report the diagnosis, the roles—and communication—become much clearer.