Every question you have about CDEI… I HAVE THE ANSWERS!!!!

Many times, the CDEI specialists and I have been asked a host of questions by the providers about the CDEI program (Clinical Documentation Excellence and Integrity Program) and thought I would share some of our FAVORITE questions and the responses…

PHYSICIAN QUESTION # 1 – “You are only issuing queries to make the patient look sicker and make money for the hospital”

CDEI RESPONSE: No… our goal is a complete and accurate medical record and our work is not predicated on dollar targets or amounts… only the accuracy of the medical record defined as acuity and severity.  Many times, the queries we issue don’t make the patient look sicker at all and in fact result in removal of a diagnosis that is not clinically supported and/or clinically valid. As an example, an ED provider might document pneumonia but there is no other physician documentation that confirms or negates the diagnosis. According to the coding rules, the diagnosis would be coded, however if the CDEI specialist reviewing the record could not find clinical support such as vital signs, chest x-rays, labs, or IV antibiotics, we would query you to ask if the pneumonia was clinical supported or clinically validated … If unable to be clinically supported, the diagnosis of pneumonia would be ruled out and thus not coded.

PHYSICIAN QUESTION # 2 – “Why is this query addressed to me? “

CDEI RESPONSE: The query can be addressed to a consultant, to the author of documentation or to the attending physician. In the case of conflicting information, the attending physician is considered “captain of the ship” and therefore receives the query so he /she can comment. The attending physician is responsible for reviewing all consultant notes, all labs, tests and diagnostics and that is why he or she is the one to receive the query for conflicting documentation.

PHYSICIAN QUESTION # 3 – “I don’t know why I received this query…  The answer is in my note… go read my progress notes”  

CDEI RESPONSE: The query was issued because there was missing or incomplete documentation in the note. Code assignment is based on physician documentation and if it’s unclear or incomplete, a query is placed. Specificity of the diagnosis provide the acuity, severity and accuracy of the patient clinical presentation as well as their clinical progression /evolution. Added benefit…  It is this specificity and detailed documentation that also supports the appropriateness of an inpatient level of care.

PHYSICIAN QUESTION # 4 – “I’m not going to answer your query “

CDEI RESPONSE: I am sorry that you feel that way and I recognize and appreciate that your time is valuable…  But please understand, an unanswered query may result in a medical record with a less than accurate clinical picture…  I am available now or later as well as my physician advisor to further discuss your specific concern…

Of note we find many records with inaccuracies … this in light of computerized dictation… some of my “favorites” which are why queries are sometimes generated are as follows:

  • “Patient had a stent at Wal-Mart “ – which should have read” patient has a stent in Vermont”
  • “Mac call me”  – which should have read “patient was recently transferred from McAuley Residence
  • “Patient recently diagnosed with cancer and received care at “was well”- which should have read as “received care at Roswell “

So in closing, please note that our CDEI specialists have and will continue to pursue and ensure that we have an accurate clinical picture for the patients you treat and that we serve at Catholic Health… I also hope that I have answered some of your “favorite” questions and as a result that you will now add the CDEI team and the CDEI program to your FAVORITES LIST!!!

 

Submitted by: Cheryl A. Friedman RN, MHA, VP of Care Management and Documentation Integrity