Based on the current situation, there is a need for change in escalating documentation and coding process. The following policies will not only help maintain the hospital documentation validity but also ensure that the information is useful for internal use. The proposal comes in light of the pending query loads with the physician. The proposal is guided by AHIMA/ACDIS provision.
According to AHIMA, all cases regarding clinical validity and practitioner documentation should first be referred to the to the CDI manager. The CDI should establish the inconsistencies and escalate the issue to the relevant authority based on the source of the validity situation, such to HIM when the case involves the physicians. HIM, for example, will consult the relevant authority and provide a comprehensive feedback to the CDI. Some of the AHIMA guidelines which are key in the current stalemate include: (CDI, 2013).
- The administrative representative should the CDI manager of the concurrence
- The administrative representative if no satisfied with the existing documentation should discuss the case with the relevant practitioner. The practitioner should be subjected to clarifying the documentation.
- In case of a significant disagreement and the administrative representative cannot solve, relevant medical staff should be involved for further review. A committee can be formed including the CDI, HIM, CFO, CIO, and CEO.
b. Escalation steps should be tracked to ensure internal compliance purposes, such as in CDI worksheet and other query logs.
The ACDIS/AHIMA as well have provisions for query generation and management. Under the Guidelines for Achieving a Compliant Query Process, lack of previous clinical indicators during query has been identified as an important quality parameter. The document states that query generation should be given a lot of consideration during health record documentation. This statement raises the important of previous query data and the importance of their storage, as such CDI should not discard any queried information. Such queries can be useful in many ways, including: (CDI, 2013).
- In analyzing conflicting, incomplete, imprecise, ambiguous, illegible, or inconsistent information.
- Drawing association with clinical data that present no definitive relationship to the basic diagnosis
- Provide a history to diagnostic evaluation, clinical indicators, or none case specific interventions
- The logs are necessary in determining the frequency of possible diagnosis without clinical validation
This proposal policies provide a unique avenue for CDI to work with other members of the quality management team, such as CDI, HIM, CFO, CIO, and CEO with limited interference but in a collaborative manner. It will help remove practioners from potential blames while at the same time solidifying their efficiency in raising any arising clinical matters they might have stumbled upon during medical records evaluation. While the CDI can query practioners directly, being in contact with HIM is important to access the situation before, for example, a physician is put on the line of fire. This is in line with the “Guidelines for Achieving a Compliant Query Process” which states that “When a practitioner documents a diagnosis that does not appear to be supported by the clinical indicators in the health record, it is currently advised that a query be generated to address the conflict or that the conflict be addressed through the facility’s escalation policy” (CDI, 2013, pg. 2). The escalation policy hence remains a vital quality indicator.
While the CDI can simple query the practitioners directly, it is important to note the importance of the facility’s escalation policy. In physician query cases CDI should contact HIM manager, to review the case and provide necessary information. HIM will review the case, and contact the effected practitioner if deemed necessary. Similarly, HIM can escalate the issue with the CFO and CEO if it can establish that situation was beyond a practitioner and a systematic challenge caused by deficiencies on their part. The escalation process is important to minimize administrative burden upon some few individuals.
CDI. (2013). Escalation policy addendum added to new AHIMA/ACDIS query practice brief. Cdi Journal. Vol. 7 No. 3.