2019 UPDATE ON THE GUIDELINES FOR ACHIEVING A COMPLIANT QUERY PRACTICE

1. 2019 UPDATE ON THE GUIDELINES FOR ACHIEVING A COMPLIANT QUERY PRACTICE ASSOCIATION OF CLINICAL DOCUMENTATION INTEGRITY SPECIALISTS INDIANA CHAPTER INDIANAPOLIS, INDIANA SEPTEMBER 20, 2019 Danita Forgey Consulting

2. Uniform Hospital Discharge Data Set (UHDDS) • National Center for Health Statistics • First appeared in Federal Register 1985 • First version was for hospital inpatients only • Now expanded to include most healthcare settings • Minimum data set • Patient identifiers • Hospital identifier • Physician identifier • Admission and discharge dates • Diagnoses and procedures • Patient disposition • Expected principal payment source Danita Forgey Consulting LLC

3. UHDDS • Provides definition of principal diagnosis • That condition established, after study, to be chiefly responsible for occasioning admission of the patient to the hospital for care • Other diagnoses • Conditions that coexist at the time of admission, that develop subsequently, or that affect treatment received and/or length of stay Danita Forgey Consulting LLC

4. ICD-10-CM • Maintained by World Health Organization • ICD-10 vs ICD-10-CM • Uses • Mortality reporting • HIPAA recognized code set for diagnosis reporting for health care providers • ICD-10-PCS is the HIPAA recognized code set for inpatient procedure coding Danita Forgey Consulting

5. Principal Diagnosis Selection • Codes for symptoms, signs and ill-defined conditions • Two or more diagnoses that equally meet the definition of principal diagnosis • ICD-10-CM chapters with specific sequencing guidelines • Obstetrics • Complications of Surgery and Medical Care

6. Guidelines for Reporting Other Diagnoses • Reportable secondary diagnoses meet one of the following criteria: • Clinical evaluation • Therapeutic treatment • Diagnostic procedures • Extended length of hospital stay • Increased nursing care and/or monitoring • Unconfirmed conditions • Diagnostic information copied into provider notes

7. Evolution of Clinical Documentation Improvement Danita Forgey Consulting LLC

8. AHIMA Standards of Ethical Coding • Apply accurate, complete, and consistent coding practices that yield quality data • Gather and report all data for internal and external reporting in accordance with applicable requirements and data set definitions • Report only codes and data that are clearly and consistently supported by documentation • Query and/or consult with provider for clarification and additional documentation before assigning code(s) Danita Forgey Consulting LLC

9. AHIMA Standards of Ethical Coding • Refuse to participate in, support, or change reported data and/or narrative titles, billing data, clinical documentation practices, or any coding related activities intended to skew or misrepresent data and their meaning  • Protect confidentiality of health information • Advance coding knowledge through continuing education • Facilitate, advocate and collaborate with health care professionals in the pursuit of accurate, complete and reliable coded data Danita Forgey Consulting LLC

10. ACDIS Code of Ethics • Protect confidentiality and the individual’s right to privacy • Refuse to cooperate with, or condone by silence the actions of those who engage in fraudulent, deceptive, or illegal acts • Support the reporting of all healthcare data elements required for external reporting purposes • Advance their specialty knowledge and practice through continuing education, research, publications, and presentations Danita Forgey Consulting LLC

11. ACDIS Code of Ethics • Facilitate accurate, complete, and consistent clinical documentation • Facilitate interdisciplinary collaboration in supporting CDI practice Danita Forgey Consulting LLC

12. What is a Query? • Communication tool or process used to clarify documentation in the health record • Accurate code assignment • Documentation integrity • Clinical data that accurately depicts patient complexity Danita Forgey Consulting LLC

13. Clinical Indicators • Documentation that supports a diagnosis as reportable • Documentation that establishes the presence of a condition • Identified from sources in the patient record • Specific to the patient and episode of care • Used to support why a more complete or accurate diagnosis or procedure is sought • Used to support why a diagnosis requires additional clinical support to be reportable Danita Forgey Consulting LLC

14. When to Query? • Resolve conflicting documentation between attending provider and other treating providers • Clarify the reason for admission (principal diagnosis) • Clinical validation • Establish a link between conditions • Establish acuity or specificity • Clarify a condition documented as “history of” • POA indicator assignment • Establish whether a condition was ruled out • Clarify the objective or extent of a procedure Danita Forgey Consulting LLC

15. Who to Query? • Licensed, independent practitioners who render patient care • Physician or any qualified healthcare practitioner who is legally responsible for establishing the patient’s diagnosis • Attending physician is the provider responsible for establishing the patient’s diagnoses • May query non-providers when that professional provides the service • Start/stop times for infusions, mechanical ventilation by RT Danita Forgey Consulting LLC

16. Types of Queries • Concurrent, prebill, retrospective • Can be verbal, on paper, electronic • Must be compliant regardless of format • Ask that responses be consistently documented in the progress notes and/or discharge summary • Responses can be documented as an addendum • Signed and dated by responder • Verbal queries should be complaint with appropriate query practice • Document discussion to make available to other hospital departments and external agencies • Response documented in patient record Danita Forgey Consulting LLC

17. Types of Queries • Open-ended • Multiple choice • Clinically significant and reasonable options • Can provide a new diagnosis • Should include choice of unable to determine, not clinically significant, unknown, other, etc Danita Forgey Consulting LLC

18. Types of Queries • Yes/No • Only used for documented conditions that need further specification • Determining POA status • Verifying documentation from reported interpreted by other physicians • Verifying cause and effect between documented conditions • Resolving conflicting documentation Danita Forgey Consulting LLC

19. Compliant Queries • Clear and concise • Contain clinical indicators from the health record • Present facts identifying why clarification is needed • Do not include impact on quality reporting or reimbursement • Specific to the clinical scenario of the individual patient • Avoid using terms that indicate an uncertain diagnosis unless query is done at the time of discharge Danita Forgey Consulting LLC

20. Compliant Queries • Identify patient • Identify person querying, including contact information • Identifies provider to whom the query is addressed • Signed and dated Danita Forgey Consulting LLC

21. When to Use Information from Prior Encounters • Specificity of a currently documented diagnosis • Determining prior patient baseline • Establishing a cause-and-effect relationship • Determine the etiology of current signs/symptoms • Verify POA indicator status • Clarify a prior history of disease that is no longer present Danita Forgey Consulting LLC

22. Noncompliant Queries • Direct a provider to document a condition that • Does not exist to supply an exception for a patient safety indicator • Adds a nonreportable condition • Encourages a provider to neutralize documentation suggestive of a postsurgical complication • Is not supported by clinical indicators • Lead a provider to document a condition that is not supported by documentation • Include impact on reimbursement or quality measures Danita Forgey Consulting LLC

23. Query Example ED physician documented that patient presented to the ED complaining of weakness and confusion. Final impression was: Sepsis, AKI, community acquired pneumonia Pulmonary consult note on 4/22 said he was admitted with pneumonia, sepsis WBC elevated at 25, lactate 29 and chest x-ray showed bibasilar opacities which may represent atelectasis vs pneumonia Patient treated with IV Merepenem Danita Forgey Consulting LLC

24. Query Example • Please specify if you concur with diagnosis of sepsis. Please also document an associated infection • If sepsis was ruled out, please provide corresponding diagnosis for patient’s clinical picture and associated treatment Danita Forgey Consulting LLC

25. Query Example Acute congestive heart failure was documented in the H&P. The patient was started on IV Lasix and an echocardiogram was done The PN on 4/22 says the patient has decreased ejection fraction. Based on the clinical indicators and your professional judgement, please complete by selecting one the options below: • Acute systolic heart failure • Acute diastolic heart failure • Chronic systolic heart failure • Chronic diastolic heart failure • Acute and chronic systolic heart failure • Acute and chronic diastolic heart failure • Other (please specify) • Unable to determine Danita Forgey Consulting LLC

26. Query Example The chest x-ray on 4/12 says the patient has a bibasilar infiltrate, possible pneumonia. The H&P says the patient has COPD exacerbation with acute bronchitis and the patient was started on IV ceftriaxone. Does this patient possibly have pneumonia? Yes No Unable to determine Danita Forgey Consulting LLC

27. Query Example The current lab findings indicate an eGFR range of 17-20 mL/min.   Clinical Indicators: Previous encounter note dated 3/18/19 documents CKD stage 4, previous lab findings over that last 3 months note an eGFR of 17-20 ml/min. Danita Forgey Consulting LLC

28. Query Example Based on your judgement and review of the clinical indicators listed below, can you please select the most appropriate diagnosis? • Acute kidney injury • CKD, stage 4 • Other explanation of clinical findings (please specify) • Clinically undetermined Danita Forgey Consulting LLC

29. Query Example DanitaForgeyConsulting, LLC

30. Query Example The diagnosis of acute renal insufficiency is documented in Progress Note 8/24 Clinical indicators for this patient include: Labs       BUN  Creat  GFR 8/24       29       1.54         44 8/25       26       1.31          54 8/26       20       1.07         >60

31. Query Example Question: Clarify which is likely the best classification (following appropriate fluid rehydration): Mild hypoperfusion secondary to dehydration (back to baseline in 1 –2 days of IVFs only) Prerenal acute renal failure/acute kidney injury secondary to dehydration only Acute renal failure/acute kidney injury due to contrast induced nephropathy (not ATN) Acute renal failure/acute kidney injury of other or unknown type, probably due to (Specify) Acute renal insufficiency only   Other (Specify) Unable to determine Danita Forgey Consulting LLC

32. Query Policies • Recommended that completed query be part of the permanent health record • Policy specifies location in record • If not part of record, maintain as a business record • Escalation policy • Reporting structure • Unanswered queries • Time frames • Clinical validation • Establish who will perform clinical validation queries Danita Forgey Consulting LLC

33. Query Policies • Data analysis • Templates • Should be used for high frequency query opportunities • Drafted by a multidisciplinary team • Approved by compliance office/legal counsel • Customizable so only appropriate choices are offered • Policies and procedures for creation, updates and annual review and instructions for use Danita Forgey Consulting LLC

34. Using Information from Prior Encounters • If a recurring condition is not documented in the current encounter, it is inappropriate to go back to previous encounters to retrieve a diagnosis without physician confirmation • Coding Clinic, 3rd quarter 2013 • This applies to coding and not queries! • A query may be initiated to clarify a diagnosis that a prior health record provided evidence to support Danita Forgey Consulting LLC

35. CDI Policies • Use for orientation for new CDI and coding staff • Use for continuing education of existing CDI and coding staff • Standardizes query practice across the organization • Useful in data analytics • Compliance • Can be shared with external auditors • Should address limits to number of queries per case • Establishes relationship between CDI and other professionals Danita Forgey Consulting LLC

36. CDI Policies • Escalation policy • Address unanswered queries • Delinquency? • Referral to physical advisor? • Report to organizational leadership? • Buy-in from organizational leadership Danita Forgey Consulting LLC

37. CDI/Coding • Should meet on a regular basis • Enhance clinical education • Discuss changes in official coding guidelines • Address physician concerns • Discuss MS-DRG issues • Discuss querying strategy • Second-level reviews • Different working and final MS-DRG • Procedures unrelated to principal diagnosis • Single MCC/CC • Sign/symptom as principal diagnosis Danita Forgey Consulting LLC

38. Physician Advisor • Recent ACDIS survey showed 64% of respondents had a physician advisor • Most had a single, part-time advisor • Roles served • Helping to close outstanding queries • Assisting CDI staff in physician education • Assisting with auditor appeals • Disciplining non-compliant physicians • Offering coding/query suggestions to CDI and coding staff • Inpatient admission necessity reviews Danita Forgey Consulting LLC

39. Resources • Uniform hospital discharge data: minimum data set; report of the National Committee on Vital and Health Statistics; April 1980 • AHIMA; Guidelines for Achieving a Compliant Query Practice (2019 Update); Journal of the American Health Information Management Association; April 2019; pp 36 – 41 • Centers for Medicare and Medicaid Services, National Center for Health Statistics; ICD-10-CM Official Guidelines for Coding and Reporting; FY2019 • Journal of the American Health Information Association; Clinical Validation: the Next Level of CDI; December 2016 Danita Forgey Consulting LLC

40. Resources • American Health Information Management Association; AHIMA Standards for Ethical Coding; 2016 • Association of Clinical Documentation Improvement Specialists; ACDIS Code of Ethics; 2018 • American Health Information Management Association; AHIMA Inpatient Query Toolkit; 2018 • Association of Clinical Documentation Improvement Specialists; CDI Journal May/June 2019; pp 8-16; Danita Forgey Consulting LLC