Success: Tips, Techniques, and Strategies to Ensure ... · Query for Success: Tips, Techniques, and...

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Sheila Duhon, MBA, RN, CCDS, A‐CCRNNational Director, Clinical Documentation Improvement Education

Tenet Healthcare, Dallas, Texas

Query for Success: Tips, Techniques, and Strategies to Ensure Physician Engagement and Reduce Risk

Patti Fountain, MBA, RN, CCDS Regional Director, Clinical Documentation Improvement

Tenet Healthcare, New England and Chicago Markets

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Learning Objectives

• At the completion of this educational activity, learners will be able to:– Describe the methodology and best practice for a healthcare

system network to enhance their CDI program for maximal performance

– Explain the benefits of a large healthcare system merging the provider query process

– Identify the 4 Cooperating Parties responsible for overseeing the development and application of coding and reporting guidelines and providing query authoritative guidance

– Reference the AHIMA and ACDIS position guidelines for an effective and compliant query process and CDI ethics

– Develop an effective and compliant query, incorporating the “TRIC” approach

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Query Process: Historical Perspective

• The provider query process was developed as a mechanism for coders to obtain the additional documentation and information required for accurate and specific code assignment.

• The first query guidelines were developed for the professional coder. These guidelines focused on using “open‐ended” questions. In general, queries were undefined and unregulated, and the processes used varied among coders and facilities.

• With the implementation of clinical documentation improvement programs in the late 1990s, responsibility for the query process was extended to non‐coders.

• The queries developed by nurses and physicians tended to be more directive (leading), and this led to concern about whether clinician queries should comply with current query guidelines.

• As concerns escalated regarding queries, those involved in the process (including coders and CDSs) sought additional guidance.

2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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Query Standards: Historical Perspective

• 2001: “Developing a Physician Query Process”

• 2008: “Managing an Effective Query Process”

• 2010: “Guidance for Clinical Documentation Improvement Programs”

• 2013: “Guidelines for Achieving a Compliant Query Process” (joint effort by AHIMA & ACDIS)

• 2016: “Guidelines for Achieving a Compliant Query Process” (2016 update by AHIMA & ACDIS)

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Authoritative Guidelines: Cooperating Parties

• The Cooperating Parties are the 4 agencies who oversee the development and application of coding and reporting guidelines:

– American Health Information Management Association (AHIMA)

– Centers for Medicare & Medicaid Services (CMS)

– American Hospital Association (AHA)

– National Center for Health Statistics (NCHS)

• Adherence to these guidelines when assigning ICD‐10 diagnosis and procedure codes is required under the Health Insurance Portability and Accountability Act (HIPAA)

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Query Basics: DO

• Use precise, professional language

• Identify documented clinical findings pertinent to the query’s intent that reflect monitoring, evaluation, or treatment of the condition

• Ask the provider to make a medical diagnosis of the clinical data

• Present the information in a concise and clear manner

• Contain CDS contact information

• Include in the body of each query:

– A brief introductory statement

– Pertinent, patient‐specific clinical indicators

– Consistent and compliant question and verbiage

– Directions on where/how to provide a response to the query


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Query Basics: DO NOT

• Pose vague or imprecise queries

• Pose queries with additional clinical information that is not directly pertinent to the intent of the query

• Pose a query without appropriate clinical information in the medical record justifying the need for a query

• Appear presumptive, directive, prodding, condescending, threatening, blaming, or as if leading to an assumed response

• Indicate financial impact, quality reporting outcomes, or public profiling (hospital or physician) outcomes

• Require only a physician signature as the response (per your facility bylaws)

• Query for incidental, insignificant, or irrelevant findings

• Use terminology such as “for coding purposes” or to “capture a CC or MCC”

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Tenet: Key Components of a Successful Query Process

• ACDIS guidelines• AHIMA guidelines• Tenet policies & procedures • Tenet query committee• Tenet compliance, coding, and CDI• Physician leadership

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Tenet Healthcare and Vanguard Healthcare came under one umbrella in 2013, forming a system with over 80 acute care facilities, spanning several geographic regions nationally and internationally.


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1010

Tenet Healthcare

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Tenet: CDI Best Practices Evolution

“Legacy” Tenet• Organization‐based, defined CDI

program

• Electronic CDI platform

• Designated CDI leadership reporting to HIM

• CDI reviews focused on market payer population

• Physician advisor in each facility across all markets

• CDI program initiated in 2007, beginning with the physician advisor and addition of CDS role in 2008

• Query form is not part of the permanent medical record: MD response is in the body of the record

• Concurrent and retrospective queries are differently formatted

“Legacy” Vanguard• Individual facility–based, defined CDI program

• Manual/paper CDI platform

• Designated coding leadership reporting to HIM

• CDI reviews focused on designated payer populations

• Physician advisor in limited facilities across the organization

• CDI program initiated in 2006, beginning with the CDS role and addition of physician advisor role intermittently thereafter

• Query form is part of the permanent medical record: MD response is in the body of the record or in the query form

• Concurrent and retrospective queries are identically formatted

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Physician Engagement in the CDI & Query Process

• Tenet query policy

• Tenet query procedure

• Tenet query template

• Tenet SharePoint

• Tenet national CDI physician advisor

– Tenet facility‐dedicated physician advisors

• Tenet physician advisor CDI training

– Physician‐led, physician‐oriented, on‐site


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The “TRIC” to Query Success

• Treatment– What specific and pertinent treatments are consuming resources

(monitoring, evaluation, or treatment)?

• Risk– What is the risk to the patient for the diagnosis?

• Indicators– Which clinical indicators are pertinent to the process of making a

medical diagnosis?

• Compliant question– Is the intent of the question clear—without being leading, presumptive

or directive?

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Tenet Standardized Query Template

DemographicsDemographics

“TRIC”“TRIC”

OptionsOptions

Question&

Response

Question&

Response

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1. “History of heart failure” per

H&P (Risk)2. Lasix 40 mg IV BID per MD orders & medication record

(Treatment)3. “…pulmonary vascular prominence suggestive of heart failure…” per CXR report 10/15

(Risk)4. BNP‐1257 per admission labs

(Indicator)5. Ejection fraction 28% per

ECHO report 10/15 (Indicator)

1. “History of heart failure” per

H&P (Risk)2. Lasix 40 mg IV BID per MD orders & medication record

(Treatment)3. “…pulmonary vascular prominence suggestive of heart failure…” per CXR report 10/15

(Risk)4. BNP‐1257 per admission labs

(Indicator)5. Ejection fraction 28% per

ECHO report 10/15 (Indicator)

(Compliant Question) (Compliant Question)

The “TRIC” to HF Specificity


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Operationalizing the Query ProcessMarket and Facility Level

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Tenet Healthcare Query Committee

CDI Specialists

Coding

TenetQuery CommitteeComponents

Compliance

Physician

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Communicating the Query Process

Tenet Home Office

Regional Representation

Market Membership

Facility Clinical Documentation Specialist


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Evaluation of CDS QueriesProcess and Data Analytics Examples

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Quarterly Query Reviews

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Query Analytics: CDSClinical Documentation Specialist #1

Query Type# MD Queries

% MD Response

Rate Agreed Disagree UTD Alt Dx

% MD AgreeRate

No Response

56 84 40 0 4 3 85 9

Altered Mental Status 6 83 2 0 2 1 40 1

Anemia Specificity 1 100 1 0 0 0 100 0

Cause Effect Confirmation 1 100 1 0 0 0 100 0

Clarification of Clinic or D 15 73 10 0 1 0 91 4

Conflicting MD Docume 3 100 2 0 0 1 67 0

Diabetes Specificity 2 50 1 0 0 0 100 1

Diagnosis/Impression Validat 1 100 1 0 0 0 100 0Encephalopathy Specificity 1 100 1 0 0 0 100 0

General Documentation 2 100 1 0 0 1 50 0

Heart Failure Specificity 5 100 5 0 0 0 100 0

InPatient Debridement Specif 1 100 1 0 0 0 100 0

Infection Specificity 1 100 1 0 0 0 100 0

Nutritional Clarification 6 83 5 0 0 0 100 1

Present on Admission (POA) D 3 100 3 0 0 0 100 0

Procedure Clarification 1 0 0 0 0 0 0 1

Renal Condition Specificity 2 100 2 0 0 0 100 0

Respiratory Severity Specifi 2 50 1 0 0 0 100 1

Urinary Condition Specificit 3 100 2 0 1 0 67 0

Clinical Documentation Specialist #2


% MDResponse

Rate Agree Disagree UTD Alt Dx

% MD AgreeRate

No Response

24 78 17 0 1 0 94 5

Anemia Specificity 5 60 3 0 0 0 100 2

CKD Speci 2 50 0 0 1 0 0 1

Clarification of Clinic or D 4 100 4 0 0 0 100 0Clinical Findings 1 0 0 0 0 0 0 1

Clinical Significance 1 0 0 0 0 0 0 1

Diabetic Associated Manifest 1 100 1 0 0 0 100 0

Documentation Clarification 1 100 1 0 0 0 100 0


Malnutrition ‐Specificity o 1 0 0 0 0 0 0 0Medication/Diagnosis Correla 1 100 1 0 0 0 100 0

Nutritional Clarification 2 100 2 0 0 0 100 0POA Diagnosis Clarification 1 100 1 0 0 0 100 0

Procedure Clarification 1 100 1 0 0 0 100 0

Skin Ulcer 1 100 1 0 0 0 100 0

Skin Ulcer Location and POA 1 100 1 0 0 0 100 0


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Query Analytics: Physician

Physician #1


% Response

Rate Agree Disagree UTD Alt DxAgreed Rate NR

MD #1 15 80 9 1 1 1 75 3

Cause Effect Confirmation 4 100 2 1 0 1 50 0

Clarification of Clinical Fdgs 6 50 3 0 0 0 100 3

Conflicting Physician Documentation 1 100 1 0 0 0 100 0

General Documentation Clarification 1 100 0 0 1 0 0 0


InPatient Debridement 1 100 1 0 0 0 100 0

Pneumonia Specificity 1 100 1 0 0 0 100 0

Physician #2


% MD Response

Rate Agree Disagree UTD Alt Dx% Agreed Rate NR

MD #2 13 85 11 0 0 0 100 2

303 Anemia Specificity 1 100 1 0 0 0 100 0

306 Atrial Fibrillation or Flutter 2 50 1 0 0 0 100 1

309 Cause Effect Confirmation 1 0 0 0 0 0 0 1

313 Clarification of Clinical Fdgs 2 100 2 0 0 0 100 0

322 Diabetes Specificity 1 100 1 0 0 0 100 0

328 General Documentation Clarification 2 100 2 0 0 0 100 0

331 Heart Failure Specificity 3 100 3 0 0 0 100 0

362 Renal Condition Specificity 1 100 1 0 0 0 100 0

*NR = No Response

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Case Study: Query Practicum Study 1: Conflicting Documentation

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Case Study 1: Conflicting Documentation ED MD: 65‐year‐old female presents with fever, vomiting, and diarrhea…For past 5 days has had decreased

PO intake 2/2 nausea. Has been unable to take her baclofen and other meds for 2 days. Gradually increasing confusion. Fever reached 103F today so called EMS…h/o MS.

01/31/17 H&P: “65 year‐old admitted with nausea, vomiting, diarrhea, and fever…pneumonia”

02/01/17 Progress note: “…Pneumonia…”

02/02/17 Progress note: “…Sepsis 2/2 CAP…”

02/03/17 Progress note: “…Pneumonia…”

A&P: Pneumonia…continue IV abx, obtain sputum culture, PRN acetaminophen for temp > 100 (PO)

Labs: Serial white blood count: 18.9—13.5—9.7—9.3—10.8

Lactic acid on admission: 2.8

% bands: 12

Vital Signs: T 103–101.5 F HR 110–122

12/13/15 CXR: Study is compared to examination of 01/01. Patient has increasing lingular pneumonia. On frontal projection the airspace disease has a somewhat nodular appearance. Follow‐up to clearing is recommended. No effusions are seen. Right lung is clear. Vascular markings are normal. There is scoliosis of the spine.


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Case Study 1: Conflicting Documentation

Query Template Query

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Case Study 1: Infection Specificity


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Case Study: Query PracticumStudy 2: Urinary Condition Specificity


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Case Study #2: Urinary Condition Specificity

10/01/16 H&P: “Urinary tract infection. Currently, the patient does not have any signs of wound infection and his fever is most likely due to urinary tract infection…”

PMH: “Quadriplegia. The patient is s/p C6 level quadriplegia with chronic indwelling Foley catheter last changed one month PTA…”

Labs: UA +/urine culture: pyuria > 8 WBC with positive urine culture ≥ 100,000 colonies

A&P: Patient presenting with fever and leukocytosis.

1. Decubitus ulcer. “The patient has stage III decubitus ulcer, but it is less likely his fever is forecasting, it is well managed and there is no pus on the examination and no redness.”

2. UTI. Meropenem IV as ordered.

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Case Study #2: Urinary Condition Specificity

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Case Study: Query Practicum Study 3: AMI Specificity


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Case Study 3: AMI Specificity H&P: 76‐year‐old male with PMH of multiple CVAs/stroke, hypertension,

hyperlipidemia, cerebral artery occlusion with cerebral infarct in the past, presented to the ED with post‐cardiac arrest; revived per EMS in route to ED

Labs: CK‐MB & serial troponins elevated

EKG: Anterior leads reflect ST elevation

Progress notes: AMI, STEMI

Resident progress note: Underwent cardiac catheterization showing multiple coronary artery stenoses in LAD, no stent placed, and a temporary pacer was placed…

Attending progress note: Cardiac arrest from acute coronary syndrome with ST elevation myocardial infarction…

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Case Study 3: AMI SpecificityQuery Template Query

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Case Study: Query Practicum Study 4: Nutrition Clarification


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Case Study 4: Nutrition Clarification

H&P: “79‐year‐old male with stage III pancreatic CA with failure to thrive at home”. “…very cachectic and jaundiced...”

Physical exam: “bilateral temporal wasting…anorexia…unintentional 15# weight loss in past month”

H&P: “...history of glaucoma, hypothyroidism, anemia…admitted to the medical floor for failure to thrive and AKI…adenocarcinoma of the head of the pancreas with local invasion into the superior mesenteric artery and celiac arteries stage III…”

Progress note: “…failure to thrive/dehydration...metabolic anion gap acidosis...acute kidney injury…hypokalemia…hyponatremia...acute tubular necrosis cannot be ruled out...thrombocytopenia…likely secondary to chronic illness…”

Dietitian consult note: “…Nutrition consult ordered…recommend comfort food and fluids only, as further aggressive treatment is being refused…hospice consult per family/patient request…severely cachectic with evidence of muscle and fat wasting”

EMR: Height: 68” Weight: 112 lbs. BMI: 17.03

Progress note: “…hospice consult per family/patient request…”

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Case Study 4: Nutrition Clarification


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Polling Survey


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Polling Question #1

• Does your organization have a physician advisor/CMO/physician champion who is engaged in your clinical documentation improvement process (i.e., query, education)?

– Yes

– No

– Uncertain

– Not presently, but there are plans to add this role

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Query for Success!


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The “TRIC” to a Successful Query Process

Industry Best‐Practice Guidelines

AHIMA & ACDIS

Compliance, Coding, Physician, & CDI Partnership

Query committee

Policies & procedures

Top‐down & bottom‐up communication

Query Format

Do’s & don’ts

TRIC

Streamlined process

Internal audits

Physician Engagement

Interdisciplinary approach

Quality outcomes & data

Industry Best‐Practice Guidelines

AHIMA & ACDIS

Compliance, Coding, Physician, & CDI Partnership

Query committee

Policies & procedures

Top‐down & bottom‐up communication

Query Format

Do’s & don’ts

TRIC

Streamlined process

Internal audits

Physician Engagement

Interdisciplinary approach

Quality outcomes & data

Ensures Quality outcomes Physician engagement Risk reduction

Ensures Quality outcomes Physician engagement Risk reduction

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Reference Citations

Code of Ethics – ACDIS

https://acdis.org/membership/ethics

Ethical Standards for Clinical Documentation Professionals (CDI) Professionals – AHIMA

http://bok.ahima.org/doc?oid=101609#.WJNb82IrKos

Managing an Effective Query Process – AHIMA

http://library.ahima.org/doc?oid=84610#.WJNcJmIrKos

Guidelines for Achieving a Compliant Query Practice (2016 Update) – AHIMA

https://acdis.org/system/files/resources/compliant‐query‐practice‐2016.pdf

Tracking Your CDI Metrics: Use Data to Improve Your Program. HCPro May 10, 2011 Audio Conference.

Kruse, Marion. Physician Queries Handbook. Second ed. Danvers, MA: HCPro, 2013. Print.

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Thank you for your participation! Questions?

[email protected]@tenethealth.com

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.


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