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This is the Full Title of a Session

Clinical Validity: Assessing Clinical Indicators, Composing Nonthreatening Queries, and Avoiding Denials

Erica Remer, MD, CCDSIndependent Consultant Erica Remer, MD, Inc.Beachwood, Ohio

Kelly Skorepa, BSN, RN, CCDSDirector, Clinical Documentation IntegrityUniversity HospitalsCleveland, Ohio

2018 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:– Identify common diagnoses prone to clinical validation denials

– Assess whether clinical indicators in medical record support the clinical validity of documented diagnoses

– Compose compliant, nonthreatening clinical validation queries

– Prepare clinical validation denial appeals– Construct formative feedback for providers around clinical validation


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Scope – UH Experience

• 2017 grand total DRG downgrade denials = 769– Coding correction 453– Clinical denial 316

• Top diagnoses denied– Encephalopathy– Acute respiratory failure– Acute kidney injury– Malnutrition– Sepsis– Hyponatremia– Acidosis– Type II myocardial infarction


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Scope – UH Experience


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Traditional Versus Clinical Validation CDI

Traditional CDIDiagnoses suggested by clinical indicators but are not documented in a codable format

Clinical Validation CDIDiagnoses which are documented in a codable format, but do not seem to be supported by the clinical evidence


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Why Is Clinical Validation Such a Problem Now?

https://pixabay.com/en/photos/pharmacy/


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2011 RAC Statement of Work

Clinical validation is a separate process, which involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented. Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder. This type of review can only be performed by a clinician or may be performed by a clinician with approved coding credentials.

https://webcache.googleusercontent.com/search?q=cache:jHQxxaGxm5oJ:https://www.cms.gov/Research‐Statistics‐Data‐and‐Systems/Monitoring‐Programs/recovery‐audit‐program/downloads/090111RACFinSOW.pdf+&cd=3&hl=en&ct=clnk&gl=us


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ICD‐10‐CM Official Guidelines for Coding and Reporting FY 2018

19. Code Assignment and Clinical CriteriaThe assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.


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AHIMA’s Guidelines for Achieving a Compliant Query Practice (2016)

• Generation of a query should be considered when the health record documentation:

Provides a diagnosis without underlying clinical validation

• Lack of clinical rationale may raise questions in the event of any secondary review.


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Which Conditions?

https://pixabay.com/en/target‐bullseye‐arrow‐1133906/

• Sepsis• Acute kidney injury• Malnutrition• Encephalopathy• Acute respiratory

failure• Pneumonia • UTI• ABLA• Heart failure


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Why These Conditions?

• Medicine is an art, not a science (encephalopathy, respiratory failure)

• Shifting or no standardized clinical criteria (sepsis, malnutrition)

• Historically over‐diagnosed (UTI)• Early empiric treatment without evolution of diagnosis (pneumonia)

• Sole CC or MCC. Money is riding on it!


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Clinical Indicators

• Need to know them to recognize when a diagnosis is present, but not documented; or documented, but not present

• Coding Guidelines and Coding Clinics do NOT establish clinical indicators

• Key is to document the thought process (especially if clinical judgment deviates from established clinical indicators)


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Clinical Indicators

Would other providers come to the same conclusion based on the same information?


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What Is the Scenario?

• Condition is not present and provider is exaggerating intentionally

• Condition is not present and provider is wrong• Condition is not present and provider inadvertently failed to evolve/remove diagnosis

• Condition is present and provider is not adequately supporting it with their documentation

• Provider isn’t sure if the condition is really present or not (uncertain diagnosis?)


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Good Clinical Documentation Practice

• Evolve diagnoses• Resolve diagnoses• Remove diagnoses• Recap diagnoses in discharge summary

‐ Infiltrate, probable aspiration pneumonia with sepsis‐ Sepsis 2/2 aspiration pneumonia

‐ Sepsis resolved, continue treating aspiration pneumonia‐ Aspiration pneumonia, continue Abx

‐ D/C summary: Had sepsis secondary to aspiration PNA. Cultures negative. To finish course of antibiotics. D/C back to SNF


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Clinical Indicators


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Sepsis‐3 Versus Sepsis‐2

• Repackaged severe sepsis as “sepsis”• Sepsis with acute sepsis‐related organ dysfunction can compliantly be coded as R65.20, severe sepsis


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Sepsis

• Presumed or confirmed infection + organ dysfunction = Sepsis

• Sepsis + circulatory and cellular/metabolic dysfunction = Septic Shock

Sepsis‐2


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Sepsis‐3

Sepsis

• Presumed or confirmed infection + organ dysfunction = Sepsis

• Sepsis + circulatory and cellular/metabolic dysfunction = Septic Shock


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Only One Sepsis Definition Now, as of Jan, 2017

“Life‐threatening organ dysfunction caused by a dysregulated host response to infection”


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SOFA

SystemIndicator, with units

SOFA Score0 1 2 3 4

Respiration PaO2/FIO2, mm Hg ≥ 400 < 400 < 300

< 200 w/ respsupport

< 100 w/ respsupport

CoagulationPlatelets, x 103/µL ≥ 150 < 150 < 100 < 50 < 20

LiverBilirubin, mg/dL < 1.2 1.2-1.9 2.0-5.9 6.0-11.9 ≥ 12.0

Cardio-vascular

Doses are µg/kg/min for at least 1 hr

MAP ≥ 70 mm Hg

MAP < 70 mm Hg

Dopamine < 5 or dobutamine (any dose)

Dopamine 5.1-15 or nor/epi ≤ 0.1

Dopamine >15 or nor/epi > 0.1

CNSGlasgow Coma Scale

15 13-14 10-12 6-9 < 6

Renal Cr, mg/dL < 1.2 1.2-1.9 2.0-3.4 3.5-4.9 > 5.0

Urine output, mL/day

< 500 < 200


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qSOFA

Two of these clinical variables:

• Respiratory rate ≥ 22

• Altered mentation

• Systolic blood pressure ≤ 100 mm Hg


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Sepsis Denial

85 yo male presents on December 28, 2016 with cough, fever, and altered mental status.

The clinical evidence did not support the assignment of A41.9, (Sepsis, unspecified organism), as principal diagnosis. It was noted that the physician documented sepsis in the dc summary. To validate sepsis, the medical record is examined for consistent documentation of the condition, evidence that the patient’s presentation cannot be explained by the local infection alone or by a non‐infectious condition; and evidence of organ dysfunction caused by a dysregulated response to infection.

While the patient’s presentation warranted consideration of sepsis as a possible diagnosis, and a localized infection of pneumonia was identified, upon investigation, the diagnosis of sepsis was not supported by the clinical evidence. WBC was 16.8. Vitals: T 39.3, P 112, RR 26, BP 163/92, and SpO2 of 89%. Influenza A swab was positive.


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Sepsis Denial

Although the patient’s WBC was elevated, and the temperature, pulse, and respiratory rate was elevated as well, there was no systemic response to infection which exceeded that which would be expected with pneumonia. There was insufficient clinical evidence and supportive documentation in the records available for review to substantiate the coding of this condition.

Therefore, as a result of this review, J10.08 (Influenza due to other identified influenza virus with other pneumonia) will replace A41.9 as the principal diagnosis.


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Sepsis Appeal – Winner!

• The patient presented to the hospital with two localized infections (UTI and Pneumonia), met four SIRS criteria (T 39.3, P 112, R 26, WBC 16.8), and demonstrated acute organ dysfunction (metabolic encephalopathy and acute hypoxic respiratory failure). Based on these clinical indicators the patient met the SEP‐2 and SEP‐3 definitions for sepsis.


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• On arrival to the ED, the patient met the qSOFAcriteria with a respiratory rate of 26 (≥ 22) and altered mental status.

• Additionally, the patient had a SOFA score of 5 (≥ 2 with estimated mortality > 10%)– 3 points – Glasgow Coma Scale 6‐9

• “Altered mental status/confusion/metabolic encephalopathy”

• “Patient cannot give any history because he responds only to painful stimuli”

• “Neurological: response to pain only”– 2 points – PaO2/FiO2 < 300


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• While the patient met both SEP‐2 and SEP‐3 clinical criteria, it is important to note that these are guidelines, and the SIRS/SOFA/qSOFA scores are not meant to replace the physician’s clinical judgment pertaining to an individual patient. The physician diagnosed this patient with sepsis, and it was duly documented in multiple notes in the medical record, including in the discharge summary as a final diagnosis.


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Respiratory Failure – Lessons from Denials

… After review of the medical record, there was no documentation found that indicated significant respiratory distress or increased work of breathing. While the patient was noted to be tachypneic upon presentation, the ED MD noted the patient to “be speaking in approximately 10‐12 word sentences, not visibly with any increased work of breathing.”

• Paint a picture of accurate acuity and severity• Not static – describe worsening or improving• Tell the story … tell the truth!


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Descriptors

Sick• Toxic• Acutely ill• Looks sick• In extremis• In significant ( ) distress• Looks septic• Air hungry• Unable to speak in

sentences

Not sick• Nontoxic• Looks comfortable• In no acute distress• NAD• Looks chronically ill• Conversant


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Types of (Acute) Respiratory Failure

Hypoxemic (Type I)• Oxygen low• PaCO2 normal, low, (or high)• Often due to pulmonary

disease, like pneumonia, exacerbation of CHF, pulmonary embolism

Hypercapnic (Type II)• PaCO2 high• pH low• Can be on basis of

pulmonary, like airway obstruction; hypoventilation like opioid or ETOH OD, CVA; ineffective ventilation like neuromuscular disorders or chest wall abnormalities like flail chest


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Clinical Indicators for Acute Respiratory Failure

ABG• pO2 < 60 mmHg or <91% sat

• pCO2 > 50 and pH < 7.35

• P/F ratio (pO2 /FIO2) < 300

• pO2 decrease or pCO2increase by 10 mmHg from baseline, if known

S/Sx• Tachypnea or bradypnea• Dyspnea, shortness of breath• Accessory muscle use• Intercostal retractions• Wheezing, grunting• Cyanosis or pallor• Diaphoresis• Anxiety, confusion,

encephalopathy


32https://upload.wikimedia.org/wikipedia/commons/thumb/1/18/Acid‐base_nomogram.svg/580px‐Acid‐base_nomogram.svg.png


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Acute Respiratory Failure

• Can this patient’s respiratory system effectively oxygenate and/or ventilate without my assistance?

• Is the patient in imminent threat of morbidity or mortality without urgent intervention?


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Other Respiratory Failure Tidbits

• If not acute, might be chronic respiratory failure• Don’t have to do ABGs• Can look at respiratory therapy notes for clinical indicators, even if can’t code from them

• Should see consistency in complaints, ROS, physical exam, and treatment


35https://pixabay.com/en/kidney‐cross‐section‐medical‐organ‐2183443/

PrerenalHypovolemiaShockBurns 2/2Fluid shiftsSome meds

Intrarenal/IntrinsicAcute tubular necrosis (ATN)Acute glomerulonephritisAcute interstitial nephritisNephrotoxic medsPostrenal

Ureteral obstruction, e.g., clots, stones, extrinsic like BPH or prostate CA

AKI


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KDIGO (Kidney Disease Improving Global Outcomes)

• Acute kidney injury or impairment (AKI)• “Mounting evidence suggests that acute, relatively mild

injury to the kidney or impairment of kidney function, manifest by changes in urine output and blood chemistries, portend serious clinical consequences.” (from KDIGO)

• Dehydration does not rule out AKI [“extracellular volume contraction is the most consistent … risk factor for the development of AKI upon exposure to almost any insult”]

• Rapid resolution of AKI may be a marker of a better prognosis. Nowhere does it say that SCr needs to be elevated for 24 hours or more


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• KDIGO criteria (AKI is elevation of Cr ≥ 0.3 mg/dL in last 48 hr, or increase of ≥ 1.5 X baseline Cr (known or presumed within 1 week)

• “… reasonable in patients without CKD to assume that SCr will be stable over several months of even years, so that a SCr obtained…previously would reasonably reflect the patient’s premorbid baseline.” (from KDIGO)

• Best practice: DETAIL THE THOUGHT PROCESS


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• Provider should document why he is making the diagnosis and work‐up, monitoring, or treatment

• “AKI is still a clinical diagnosis – not all cases of AKI will fit within the proposed definition” (from KDIGO)

• Do not need to meet BOTH Cr criteria AND decreased urine output

• EER: Don’t diagnose if never out of normal range


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Encephalopathy

NINDS definition: Any diffuse disease of the brain that alters brain function or structure. May be caused by infectious agent, metabolic or mitochondrial dysfunction, brain tumor or increased pressure, prolonged exposure to toxins, chronic progressive trauma, poor nutrition, or lack of oxygen or blood flow to the brain. The hallmark of encephalopathy is an altered mental state.


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Diffuse Disease (Not Focal)

Functional (acute)• Hypoxia/hypercapnia• Shock/hypertension• Metabolic disturbances

like hyponatremia, hypo‐or hyperglycemia

• Toxins like alcohol, organic solvents, heavy metals

• Uremia• Liver failure

Structural (often chronic)• Chronic traumatic

encephalopathy• Cerebellar syndromes• Transmissible spongiform

encephalopathies• Anoxic brain damage• HIV encephalopathy


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Altered Mental State

Level of Consciousness• (Normal alertness)• Drowsy• Lethargic• Stuporous• Obtunded• (Comatose)

Cognition and Function• (Normal mentation)• Unable to concentrate• Disoriented• Confused• Noncommunicative


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Encephalopathy

• Not transient (like post‐ictal)• May be due to an infection, but not from organism• May be superimposed on dementia• No gold standard test (like EEG, serial MMSE, etc.)• Delirium has fluctuating attention• If “at baseline,” in jeopardy of denial


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OIG Turns Its Sights on Malnutrition…


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2012 ASPEN Consensus Statement

Use current references and expect auditors to do the same

• http://journals.sagepub.com/doi/abs/10.1177/0148607112440285


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There Are No Stringent Criteria

• BMI < 19, but can see in any BMI• 2 or more of the following 6:

– Insufficient energy intake– Weight loss– Loss of muscle mass– Subcutaneous fat loss– Weak hand grip– Edema may mask

• Does NOT have to be congruent with dietitian assessment. Do not HAVE to have a consult.


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Other Clinical Indicators for Malnutrition

• Words like: “malnourished, thin, skeletal, wasted, emaciated, cachectic, failure to thrive”

• Think malnutrition in: malignancy, elderly, depression, alcoholism, GI malabsorption, chronic liver or kidney disease, CHF, COPD, neurological disorders

• Other points– Not albumin or prealbumin (inflammatory response indicators)

– Potential treatments: oral supplementation; feeding tube; appetite stimulants; serial weights, dietitian support


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Pneumonia – Lessons from Denials

• “Pneumonia is not a valid diagnosis in this patient who presented with shortness of breath. VS: Afebrile, RR 20, WBC 4.4. O2 sat 96% on room air. CXR showed cardiomegaly with perihilar interstitial prominence and small pleural effusions. Repeat CXR with interval improvement of bibasilar atelectasis.”

• Common reason for legitimate denial• Empiric therapy without evolution of diagnosis


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Clinical Indicators for Pneumonia

• *Infiltrate – if early or dehydrated, may not be evident … yet

• Hypoxemia• Hemodynamic instability• Altered mental status that is severe or persistent• Dehydration that is severe or persistent• Bacteremia (septicemia, sepsis)• Moderate‐ or high‐risk Pneumonia score (PSI or CURB‐65)• Outpatient treatment failure• Immunocompromised


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Clinical Validation Queries


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Is It My Job to Question the Clinician?

https://ar.wikipedia.org/wiki/%D8%A7%D8%B3%D8%AA%D8%B1%D9%88%D8%A7%D8%AD_%D8%A7%D9%84%D8%B5%D8%AF%D8%B1#/media/File:Expiration‐left‐side‐pneumo.jpg


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Barriers to Clinical Validation Querying

• Fragile ego• Easily offended• Obnoxious• Ignorant of current clinical criteria• Unaware of internal clinical guidelines• Never taught how to document• Doesn’t understand that a query is a question


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Clinical Validation Query Process

1. Identify significant diagnosis which does not seem to be supported by clinical indicators

2. If unsure, can get second opinion from another clinician (provider, CDIS, physician advisor)

3. Generate clinical validation query1.Who?2. Diagnosis in question3. Clinical non‐indicators4.Make it compliant

4. Don’t just discount; don’t just code. QUERY!


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ACDIS White Paper 7/17

• Mere reconfirmation of diagnosis is insufficient; need documentation of clinical data/valid clinical indicators/thought process for clinical judgment call

• Verbal queries may provide opportunity to give real‐time education

• EER: Do not like the choice of “diagnosis without evidence‐based clinical criteria”

https://acdis.org/resources/clinical‐validation‐and‐role‐cdi‐professional


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Clinical Validation Query

Dr. Remer,Regarding this patient with known Alzheimer’s dementia and a chief complaint of chest pain. You documented that, “she is confused and agitated.” “Family states this is her baseline mental status.”On physical exam, she was described as, “pleasantly demented,” and she was, “Alert and oriented X2 which is typical for her.” Her neurological exam “shows no focal deficits.”Your diagnoses were:1. Chest pain2. Acute encephalopathy3. Alzheimer’s dementia


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Based on the clinical indicators and your professional judgment, do you feel that “acute encephalopathy” is a clinically valid diagnosis?• Yes, no change in diagnosis is indicated (please document your clinical support in the medical record)

• No (please update in the medical record)• Other diagnosis is indicated (please document in medical record)


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Clinical Validation Denials Management


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Types of Denials

1. Diagnosis was not present – give money back2. Diagnosis probably present, but documentation

suboptimal3. Diagnosis clearly present, documentation adequate,

good, or excellent


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AKI – Lessons from Denials

• Pt presented to ED following an unwitnessed fall at the SNF with a right intertrochanteric hip fracture. Hx of multiple medical problems including HTN, DM Type 2 and dementia. Plan included pain control, ortho consult, hypokalemia replacement of potassium and acute renal insufficiency. On admission, Cr was 1.0 (0.6 – 1.3), within the normal range, and during the inpatient stay it ranged from 1.0 to 0.42. This patient does not meet KDIGO criteria as there was no increase in SCr to >1.5 baseline which is known or presumed to have occurred within the prior 7 days.


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Types of Denials



good, or excellent


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Malnutrition – Lessons from Denials

• Severe malnutrition is not a valid diagnosis in this patient with a history of advanced Alzheimer’s dementia who presented with bilateral lower extremity deep vein thrombosis. According to the World Health Organization criteria for adult malnutrition, severe malnutrition is defined by BMI < 16, >25% weight loss, a serum pre‐albumin < 5.0 mg/dL, and overt muscle wasting. This patient’s history does document a 29 kg weight loss in the past year and muscle wasting. Serum pre‐albumin level was 26.6. The patient’s BMI was 15.2. The patient was on a regular diet with Boost supplements. Therefore, severe malnutrition has been removed as a secondary diagnosis.


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Types of Denials



good, or excellent


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Denial with Suboptimal Documentation

• Mr. Smith “presented with hypertensive urgency (254/139) in the setting of medication noncompliance. Trop 0.07 likely demand ischemia in the setting of hypertensive urgency, type II MI”. – Troponins 0.07, 0.09, 0.06– Admitted to telemetry, Heparin drip and TTE– Cardiology consult: “Troponin elevated with no EKG changes. Impression: Hypertensive urgency”.

• Payer denied MCC of STEMI/Type II MI• Concurrent query opportunity?


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Organization/System Support

• Standardized, strategic process• Dedicate adequate resources and personnel• Involve clinicians and coders as needed• Attend to deadlines; track and monitor• Analyze for frequent denial generators involve contract management?

• Identify target diagnoses proactive, concurrent clinical validation querying

• Feedback and education• Report cards/data


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Clinical Validation Denial Appeal Process

1. Choose your battles wisely2. Read the denial

– Tease out the issues and clinical indicators as presented by the reviewer

– Look up the references they quote and be sure they are current and relevant

3. Refute point by point. SPELL IT OUT FOR THEM.4. Attach or list your references

– Use current references– Evidence‐based

5. Keep a spreadsheet to track and ensure you are meeting deadlines


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Strategy for Appeal: Find Common Ground

As your denial letter states, it would not be appropriate to assign the code for encephalopathy post seizure. However, this coding guidance does not apply to this case due to the fact that the patient’s severe agitation and confusion lasted many days into the hospital stay, was the focus of extensive work‐up and treatment including IV sedation with Precedexand ICU monitoring. After epilepsy team evaluation and control of seizures with Keppra, the pt continued to have altered mental status and the dx of metabolic encephalopathy was then made. I contend that this patient’s encephalopathy was multi‐factorial in etiology and required a variety of treatment modalities to resolve.


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Denials Process Flow Chart

Patient Encounter

Documentation

Denial

Denial Management

Analysis of Trends

Feedback Education


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Denials Reconciliation Team Process

• DRG downgrade denials entered into and tracked in central database for the hospital system

• Core team of coding and CDI analysts review denials and submit appeals as deemed appropriate

• Individual feedback to coder and/or CDIS who followed the specific case

• Core team provides monthly education to coding and CDI teams based on trends –– Focus on strategies to be proactive in denial prevention– Clinical validation queries

• Provider feedback and education


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Provider Feedback

Dr. Resident,Third party payers may review a patient encounter and try to recoup money which they feel the hospital was not entitled to. Our institution has a denials team who assesses the denial and determines whether an appeal or give‐back is in order. You do not need to take any further action, other than reading this informational email.The patient encounter, E98765, MR# 12345, adm date: 1/1/17 resulted in a clinical validation denial regarding the diagnosis of acute diastolic heart failure.


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Provider Feedback

In this encounter, you stated the patient had “SOB with exertion” and “is fatigued all day recently.” PE had RR of 19, P 75, “no JVD,” and decreased BS in bases. Mild edema was noted. The BNP was minimally elevated.In the H&P, under the impression of “Chronic compensated diastolic heart failure,” you documented, “‐mildly hypervolemic” and gave the patient one dose of Torsemide, with 2g Na diet, 1800 cc fluid restriction, and daily weights. In the discharge summary, the diagnosis of “acute on chronic diastolic heart failure” was recorded.The denials team does not feel that an appeal is indicated and we are agreeing with the downgrade to chronic diastolic heart failure.


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Provider Feedback

• Take‐away points:– This patient could have resulted in a medical necessity denial as well. Observation status may well have been more suitable. You did not support need for admission.

– You followed the adage that heart failure should have acuity and type documented to get the most specific code. Good job!

– It is optimal to be consistent. If there is progression or deterioration, be explicit, so that the correct diagnosis and code can be ascertained. If a patient really has an exacerbation of CHF, you should paint a picture of a sick patient.


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Provider Feedback and Education

• Denials are teachable moments. Can ALWAYS find a pearl.

• Don’t know there is a denial unless someone tells them• How did their documentation impact on the generation of the denial?

• How can they prevent a denial in the future?• Put mentation back into documentation – why were you thinking that? Why did you do that? Why did you diagnose that?

• Redact and educate more generically


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Internal Clinical Guidelines

• Constrains medical practice, but also may reduce clinical practice variation

• Have correct parties collaborating (e.g., Do you need ID representation? Is someone familiar with coding and the required verbiage present? Don’t forget CM/UR)

• Use current evidence‐based criteria as basis• Update as often as needed• Disseminate to medical and CDI staff


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Dear Dr. Remer,Clarification is needed regarding the diagnosis of respiratory failure documented in the progress notes on days 2 and 3. Mr. Jones was admitted via the ED with dx of acute diastolic CHF exacerbation with SpO2 of 97% on room air and normal VS. He received Lasix 40 mg IV and SOB improved. Cardiology confirmed dx of acute diastolic HF and Lasix was continued; additionally, COPD exacerbation treated with 2L NC, aerosols, and IV steroids.

Impression Day 2: Acute respiratory failure, DOE. Plan: SOB, likely respiratory failure, ?CHF, off Lasix

Impression Day 3: Acute on chronic respiratory failure. Plan: Breathing improved, COPD, resp failure.

Discharge summary does not mention respiratory failure.


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In light of patient’s minimal oxygen requirements, normal vital signs, and positive clinical response to IV Lasix, aerosols, and steroids, please clarify whether the diagnosis of respiratory failure was:• Considered and ruled out?• Confirmed, as evidenced by the following clinical evidence:

(also, please resolve acuity as acute, or acute on chronic) ______________________________________________

• Other: ________________________________________


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Dr. Remer,This patient was admitted with fever, nausea and vomiting, and was diagnosed with severe sepsis. The sodium was 134 and was diagnosed with hyponatremia. The patient received 2.5 L of fluids followed by IVF @ 125 cc/hr. Hyponatremia was documented in the surgical consult on Day 1, the DPN from Day 2 and in the dc summary. Sodium on Day 2 was 135. Regarding the diagnosis of hyponatremia, based on the clinical indicators and your professional judgment, please clarify:• Did not seem to be present, in retrospect• Was clinically valid (please document your thought process)• Other diagnosis is indicated (document clinical support)


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Provider Feedback

Dr. Attending,Our hospital has received a denial for the diagnosis of acute kidney injury in this patient. You are receiving this email as feedback. You do not need to take any further action, other than reading this informational email. I have authored an appeal on your behalf. Please see attached (story: sCr 1.56; baseline is always ~ 1.0; multiple instances of documentation of AKI; treatment of hydration, avoidance of nephrotoxic agents, & serial Cr).


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Provider Feedback

• This denial might have been avoided had you:– Explicitly documented your reasoning for assuming a baseline of 1.0, since the last 4 sCr measurements over the last 2 years ranged from 0.94 to 1.01, even though you did not have one in the last 7 days

– Referenced KDIGO as your source– Included in your discharge summary the fact that the Cr normalized to 0.92 upon discharge


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Thank you. Questions?

[email protected]

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.


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