The Certified Documentation Integrity Practitioner (CDIP)

The manager of HIM/Coding should be included as a key stakeholder in the clinical documentation integrity (CDI) steering committee to promote CDI initiatives because they are responsible for overseeing the coding and billing processes, ensuring compliance with coding guidelines and regulations, and collaborating with the CDI team to resolve coding and documentation discrepancies. The manager of HIM/Coding can also provide feedback on the CDI program’s impact on coding quality, accuracy, productivity, and reimbursement. (CDIP Exam Preparation Guide)

References :

CDIP Exam Content Outline 1

CDIP Exam Preparation Guide 2

The Agency for Healthcare Research and Quality (AHRQ) provides external benchmarks to examine the effectiveness of a facility’s clinical documentation program by developing and disseminating quality indicators (QIs) that measure various aspects of health care quality, such as patient safety, outcomes, efficiency, and effectiveness. These QIs are based on administrative data and can be used to compare the performance of different health care providers or facilities across the nation. The QIs include inpatient quality indicators (IQIs), patient safety indicators (PSIs), prevention quality indicators (PQIs), and pediatric quality indicators (PQIs).  These QIs can help clinical documentation improvement (CDI) programs identify areas of improvement, monitor trends, and evaluate the impact of CDI interventions on health care quality  2 .

References :  1 : Clinical Documentation Improvement Programs: Quality, Efficiency | Deloitte US Analysis  2   2 : AHRQ Quality Indicators  3

One of the best practices for writing a compliant query is to include all relevant clinical indicators from the health record that support the need for clarification and the query options. Clinical indicators are objective and measurable signs, symptoms, laboratory results, diagnostic test results, medications, treatments, and other documented findings that are related to a specific diagnosis or condition. Including clinical indicators helps to provide the rationale for the query, avoid leading or suggesting a desired response, and ensure that the query is based on evidence and not assumptions. The other options are not best practices for writing a compliant query. Directing the physician to a specific diagnosis is leading and noncompliant. Using the term “possible” to describe a condition or diagnosis when uncertain if the diagnosis is present is vague and imprecise. Using a yes/no query format for specificity of a diagnosis is discouraged, as it limits the provider’s choices and may not capture the true clinical picture.

Inconsistent clinically relevant queries may make physicians lose respect for CDI efforts and disengage because they may perceive them as irrelevant, redundant, or contradictory. Clinically relevant queries are those that affect the quality of care, patient safety, severity of illness, risk of mortality, or reimbursement. Inconsistent queries may result from lack of standardization, conflicting guidelines, poor communication, or lack of clinical validation.  To avoid inconsistency, CDI practitioners should follow best practices such as using evidence-based criteria, adhering to query policies and procedures, collaborating with coding and quality staff, and seeking feedback from physicians and physician advisors  2 .

References :  1 : AHIMA CDIP Exam Prep, Fourth Edition, p.  136  3   2 : Proactive CDI: Tackling the Problem of Physician Engagement  4

 One of the factors that an organization should consider when developing a query retention policy and procedure is if the query is considered part of the health record or not.  According to the AHIMA/ACDIS query practice brief 1 , a query is considered part of the health record if it meets any of the following criteria:

It is used to clarify documentation that affects code assignment or other data elements

It is used to support clinical validation of a diagnosis or procedure

It is used to support medical necessity or quality indicators

It is used to communicate clinical information between providers If a query is part of the health record, it should be retained according to the organization’s health record retention policy and procedure, which should comply with federal, state, and local laws and regulations. The query retention policy and procedure should also address issues such as:

The format and location of the query (e.g., paper, electronic, hybrid)

The security and confidentiality of the query

The accessibility and availability of the query

The ownership and custodianship of the query

The legal implications and evidentiary value of the query

References :

CDIP® Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf)

Guidelines for Achieving a Compliant Query Practice—2022 Update 1

A leading query is one that suggests a specific diagnosis, condition, or treatment to the provider, or implies that a certain response is desired or expected. A leading query can compromise the integrity and accuracy of the documentation and the coded data, and may also raise compliance and ethical issues. A query should be non-leading, meaning that it presents the facts from the health record without bias or influence, and allows the provider to use their clinical judgment to determine the appropriate response.

The query in the question is leading because it implies that the patient’s CHF is systolic by asking a yes/no question that only offers one option. A non-leading query would ask an open-ended question that offers multiple options, such as “What type of CHF does this patient have?” or “Please specify the type of CHF: systolic, diastolic, or combined.”

References :

CDIP Exam Preparation Guide, 2021 Edition. AHIMA Press. ISBN: 9781584268530

Guidelines for Achieving a Compliant Query Practice—2022 Update | ACDIS

Guidelines for Achieving a Compliant Query Practice (2019 Update) - AHIMA

The Provider Query Toolkit: A Guide to Compliant Practices

The appropriate action in this case is to query the physician to see if acute renal failure is clinically supported. This is because the patient has signs and symptoms of acute renal failure, such as oliguria, pulmonary edema, and elevated creatinine, but the diagnosis is not documented in the medical record. Acute renal failure is a clinical syndrome characterized by a rapid decline in kidney function and accumulation of metabolic waste products. It can be caused by various factors, such as dehydration, hypovolemia, sepsis, nephrotoxins, or obstruction.  Acute renal failure can be classified according to the RIFLE criteria (Risk, Injury, Failure, Loss, End-stage kidney disease) or the AKIN criteria (Acute Kidney Injury Network), which are based on changes in serum creatinine and urine output  2 3 . A query to the physician is needed to confirm or rule out the diagnosis of acute renal failure, specify the etiology and severity of the condition, and document any associated complications or comorbidities. A query to the physician will also improve the accuracy and completeness of the documentation and coding, and reflect the true clinical picture and resource utilization of the patient.

References :  1 : AHIMA CDIP Exam Prep, Fourth Edition, p.  133  4   2 : Acute Kidney Injury: Diagnosis and Management | AAFP  3 : AKIN Classification for Acute Kidney Injury (AKI) - MDCalc

The proper sequencing of the principal and secondary diagnoses in this case is as follows:

Principal diagnosis: Acute appendicitis. This is the condition, after study, that occasioned the admission to the hospital, according to the ICD-10-CM Official Guidelines for Coding and Reporting. The patient was admitted for laparoscopic surgery, which is a definitive treatment for acute appendicitis. The physician documented “possible acute appendicitis or probable Meckel diverticulitis” as the cause of the right lower quadrant abdominal pain. According to the AHA’s Coding Clinic, Fourth Quarter 2016, pp. 147-148, when a physician documents two diagnoses connected by “or”, coders should query the physician for clarification if possible. However, if a query is not possible or not answered, coders should assign codes for both conditions, unless one of them has been ruled out or confirmed by further testing or treatment. In this case, there is no indication that either acute appendicitis or Meckel diverticulitis has been ruled out or confirmed by further testing or treatment. Therefore, both conditions should be coded and reported. However, only one of them can be the principal diagnosis.  Since acute appendicitis is more commonly associated with laparoscopic surgery than Meckel diverticulitis, and since it has a higher relative weight than Meckel diverticulitis under the MS-DRG system, it is reasonable to select acute appendicitis as the principal diagnosis  2 3 .

Secondary diagnosis: Right lower quadrant abdominal pain. This is a sign or symptom that is associated with the principal diagnosis and requires clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increased nursing care and/or monitoring. The patient presented with right lower quadrant abdominal pain as a manifestation of acute appendicitis or Meckel diverticulitis. The pain required clinical evaluation by abdominal ultrasound and therapeutic treatment by laparoscopic surgery.  Therefore, it should be coded and reported as a secondary diagnosis  4 .

Secondary diagnosis: Type I diabetes mellitus. This is a chronic condition that affects the patient’s care in terms of requiring diagnostic or therapeutic services or affecting patient outcomes or resource utilization. The patient has a history of type I diabetes mellitus and received an injection of neutral protamine Hagedorn insulin to normalize the blood sugar level prior to surgery.  Therefore, it should be coded and reported as a secondary diagnosis  4 .

References :  1 : AHIMA CDIP Exam Prep, Fourth Edition, p.  133  2 : ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section II.A  3 : AHA Coding Clinic for ICD-10-CM and ICD-10-PCS, Fourth Quarter 2016  4 : ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section III.C : AHIMA CDIP Exam Prep, Fourth Edition https://my.ahima.org/store/product?id=67077