A common principal diagnosis being denied is "unspecified hypotension." The RACs are denying this diagnosis when it is associated with medications, acute renal failure and/or dehydration, utilizing the official coding guidelines to support their decision. If the etiology of hypotension is unclear in the medical record, query the attending to document it after study.
Pneumonia with hemoptysis is another issue for which the hemoptysis should not be coded unless it is documented as being unrelated to the pneumonia or its etiology is unknown. "Hemorrhagic" is a nonessential modifier in the index of the coding book under the term for pneumonia and therefore would not be coded. If it appears that the etiology may be due to another condition or the etiology is unknown, query the attending to document it after study.
Cases also are being denied when a patient has "bacteremia," "sepsis," and "urosepsis" documented in the medical record but only "urosepsis" is documented on the discharge summary: this case also would require a physician query to clarify which diagnosis was made after study.
Another advisable common query to physicians would be asking them to document the etiology of diagnoses documented in the postoperative period, or asking them to document the qualifier "due to" since such diagnoses aren't always connected to the procedure.
The RACs also will target the abbreviation I&D, assuming it means "incision and drainage," when there is insufficient documentation to describe what procedure actually was performed. Always query the surgeons to spell out this abbreviation and support the procedure by describing in detail what actually was done.
Why does a coder or clinical documentation specialist query a physician? For several reasons:
- To clarify a diagnosis (i.e. urosepsis, bacteremia).
- To obtain a specific diagnosis for a symptom.
- To determine a principal diagnosis.
- To determine if there is a cause-and-effect relationship between two diagnoses or a test result and a diagnosis.
- To identify diagnoses that are present on admission.
Compliant physician queries first should list the pertinent clinical findings in the medical record to justify the query.
The following are examples of appropriate physician query techniques:
These two queries can be used to determine if there is a cause-and-effect relationship between diagnoses and/or between a test result and a diagnosis.
- The patient has type II diabetes in the H&P. The March 28 progress note states that the patient has neuropathy and is being treated with Neurontin. Please document the relationship, if any, between the diabetes and the neuropathy.
- The patient was admitted with pneumonia. The sputum culture was positive for staphylococcus. Coders cannot code from laboratory test results. Please document the significance of this finding in relationship to the patient's pneumonia.
These three queries can be used to clear up conflicting physician documentation.
- There is conflicting documentation in the medical record. The attending physician states that the patient has bacteremia, which is a nonspecific term that codes to an abnormal lab finding. Bacteremia indicates a transiently positive blood culture without clinical symptoms. The consultant states the patient has sepsis, which is an acute, life-threatening illness that adversely affects organ perfusion. After study, which condition does the patient have?
- Please clarify as there is conflicting documentation in the chart. The Jan. 20 progress note states that the patient has a UTI with sepsis. The Jan. 23 progress note states the patient has septicemia. The discharge summary states the patient has urosepsis without mentioning septicemia or sepsis. These diagnoses all have different code assignments. Please provide further documentation as to whether the patient has a simple UTI or the patient has sepsis and/or septicemia due to a UTI.
- This patient has an elevated BUN of 50 and Creatinine 4.0. The GFR was 30. The diagnoses "acute renal insufficiency" and "acute renal failure" are documented interchangeably. Please note that these terms are not synonymous, and additional documentation is needed to clarify which diagnosis best describes the patient's renal condition after study.
These queries can be used for obtaining documentation to further specify a diagnosis.
- This patient was admitted from the nursing home with pneumonia. She is status post a CVA with hemiplegia, dysphagia and a PEG tube. A barium swallow was done with positive results. The discharge diagnoses are pneumonia and old CVA with hemiplegia. After study, has the etiology of the patient's pneumonia been determined, and can it be specified further?
- This patient is admitted with bradycardia. The heart rate on admission was 45 and was noted to have increased to 117. The patient also has atrial flutter, which was treated. Can the severity of the patient's bradycardia be specified further?
This query can be used to improve physician documentation regarding the significance of pathology results.
- Coders cannot code from pathology reports or laboratory test results. The pathology report findings support the diagnosis of lymph node metastasis. Please document in the medical record the significance of the patient's pathological findings.
This query can be used to obtain a specific diagnosis for a symptom.
- This patient was admitted with chest pain. The stress test was negative and the last progress note stated that the patient was discharged on Prilosec. No other diagnoses are documented for this patient. A symptom should not be the PDX when the underlying cause is known. Please document the etiology, if known, of the patient's chest pain.
This query can be used to determine a principal diagnosis.
- The last progress note states that the patient presented with abdominal pain due to diverticulitis or radiation colitis. Please provide the diagnosis after study that occasioned the admission to the hospital.
These queries can be used to obtain documentation for the etiology of a condition.
- This patient was admitted to the hospital with back pain due to a compression fracture of the L5 vertebra. The x-ray reveals the fracture with osteoporotic changes. The patient was treated with Vicodin, Fosamax and calcium supplements. Please document the etiology of the patient's compression fracture, if known.
- This patient has cellulitis in the antecubital area of the left upper extremity. The H&P states that the patient recently was discharged from the hospital for IV chemotherapy for breast cancer. Please document the etiology of the cellulites, if known.
Writing compliant queries takes practice. Training is necessary so that nursing personnel and/or coders understand the query process and its application.
Avoid RAC attacks by educating your physicians about how to document diagnoses and procedures to their highest specificity.
About the Author
Mary Mills, RHIT, CCS is the president and CEO of Documentation Solutions LLC, a corporate compliance consulting firm that implements clinical documentation improvement programs utilizing the talents of coders and nurses working together as a team in performing the concurrent medical record review process since 2001.
Contact the Author
Resources: 2010 MS-DRG Workbook written by Mary Mills, RHIT, CCS