acdis outpatient query position paper: panel discussion paper session_final.pdfreview processes, and...

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ACDIS Outpatient Query Position Paper: Panel Discussion

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Today’s Panelists

Brian MurphyKaren NewhouserLaurie Prescott

Jessica VaughnDeanne Wilk

2018 Copyright, HCPro, a brand 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:– Describe how and why the ACDIS Advisory Board created the Position Paper, Queries in Outpatient CDI: Developing a Compliant, Effective Process

– Apply the Official Guidelines for Coding and Reporting and query guidance to the outpatient setting

– Identify compliance risks unique to outpatient CDI

– Evaluate guidance from the position paper related to management of the problem list

– Apply guidance from the position paper related to use of prior information when formulating a query

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Let’s Start With a Poll Question …

• Have you read the ACDIS Position Paper,Queries in Outpatient CDI: Developing a Compliant, Effective Process?

– Yes–No–Not sure

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Why Was the Position Paper Necessary?

• ACDIS Advisory Board met prior to the 10th

annual conference in Las Vegas, NV

• Decided that outpatient CDI was the “Wild West”

– General concern with lack of query guidance related to outpatient CDI practice

– False Claims Act cases related to upcoding of HCCs/Medicare Advantage patients


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Why Was the Position Paper Necessary?

• Decided that ACDIS needed to publish guidance. This paper must:– Address the current landscape of outpatient CDI and compliance risks. One

example is vendor applications that flag HCCs and only offer diagnoses that impact HCC assignment. Another is managing the problem list. The risk adjustment data validation (RADV) process audits compliance with a given diagnosis, but not the query process itself.

– Acknowledge differences from inpatient CDI—and similarities. Outpatient CDI queries may look different than inpatient CDI in terms of delivery and formatting, but they should be compliant and non‐leading, and allow for independent medical decision‐making and diagnosis. The process of querying will not be the same, but the need for compliance is identical.

– Stress physician education. This need is even greater in outpatient CDI as it’s unlikely queries will be able to be performed in all or even most instances, given the volume of outpatient CDI encounters, non‐concurrent review processes, and the non‐centralized/diffuse nature of practices and clinics vs. stand‐alone hospitals. Outpatient CDI is not just prospective querying.

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How Was the Position Paper Written?

• Seven‐member sub‐committee of ACDIS Advisory Board drafted it in spring/summer of 2017

• Sections of paper were individually written; drafts were combined and reviewed by the sub‐committee in September

• Paper was reviewed by entirety of ACDIS Advisory Board, as well as additional outside reviewers

• After board approval, paper was published in January of 2018


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How Does This Paper Apply to My CDI Work?

• ACDIS is not a regulatory body and its Position Papers are not legally binding

• As a Position Paper, it is a recommended standard of practice

• Consider adopting for your organizationACDIS Position Papers are the association’s official, consensus stance on an issue. ACDIS

Position Papers set a recommended standard for the CDI industry to follow. They advocate on behalf of a certain position or offer concrete solutions for a particular problem. All current members of the ACDIS Advisory Board must review/approve a

Position Paper and are encouraged to materially contribute to its creation.

Reference: acdis.org/articles/acdis%E2%80%99‐%E2%80%9Chierarchy‐authority%E2%80%9D‐published‐articles

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Stay Tuned for Additional Query Guidance

• ACDIS and the American Health Information Management Association (AHIMA) are working on a revision to 2016 Guidelines for Achieving a Compliant Query Practice (inpatient practice brief), which will address the use of prior records

• Contents of Queries in Outpatient CDI: Developing a Compliant, Effective Process should align with that guidance


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This is the Full Title of a Session

Existing Query Guidance and Outpatient Coding Guidelines

Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIPDirector, CDI EducationMedPartnersTampa, FL

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Existing Query Guidance: When to Query

When documentation:

• Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent

• Describes or is associated with clinical indicators but does not have a definitive relationship to an underlying diagnosis

• Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure

• Provides a diagnosis without underlying clinical validation

• Is unclear regarding present on admission (POA) indicator assignment


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Existing Query Guidance: Clinical Indicators

• Clinical evidence remains the key element of a query

– “All queries should contain clinical indicators to support why the query was initiated.”

– “… a leading query is one that is not supported by the clinical elements in the health record …”

– “The justification (i.e., inclusion of relevant clinical indicators) for the query is more important than the query format.”

• Must not contain any information about impact on reimbursement

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Existing Query Guidance: Format

• Open‐ended, multiple‐choice, & yes/no acceptable

• Multiple‐choice

– Always include clinically significant and reasonable options as supported by clinical indicators in the health record

• Yes/no

– New diagnoses cannot result from a yes/no query

• Multiple‐choice and yes/no

– Include “other” and “clinically undetermined” as options

• Layout

– Either the clinical indicators or the question can be first


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Existing Query Guidance: Verbal Queries

• Capture all verbal (and written) queries

• Provide an account of any documentation that might appear out of context

• Need clinical rationale in the record for documented diagnosis

• Sticky notes and other temporary communication tools remain unacceptable

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Existing Query Guidance: Tracking, Escalation, Retention

• Establish and follow facility policies and procedures that are congruent with recognized professional guidelines

“The policy should indicate if the query is part of the patient’s permanent health record or stored as a separate business record. If the query form is not part of the health record, the policy should specify where it will be filed and the length of time it will be retained. It may be necessary to retain the query indefinitely if it contains information not documented in the health record. Auditors may request copies of any queries in order to validate query wording, even if they are not considered part of the legal health record.”


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Outpatient Coding Guidance: Official Guidelines for Coding and Reporting (OGCR)

• Section IV, Diagnostic Coding and Reporting Guidelines for Outpatient Services

– Most authoritative guidance

– “Guidelines in Section I should also be applied for outpatient services and office visits”

• Section IV.C, Accurate Reporting of ICD‐10‐CM Diagnosis Codes

– “… the documentation should describe the patient’s condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter …”

• Section IV.I, Chronic Diseases

– Code and report as many times as treatment and care is provided

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Outpatient Coding Guidance: Uniform Ambulatory Care Data Set (UACDS)

• Incorporated with UHDDS in 1996 into National Committee on Vital and Health Statistics (NCVHS) core health data elements document

• Coding Clinic First Quarter 1989, pp. 5–7– “The ambulatory care data set … will be used as the basis for

reporting outpatient care when it becomes available”

• Ambulatory conditions– “… requiring evaluation and/or treatment or management …”

• Other conditions– “… all documented conditions that co‐exist at time of

encounter/visit, and require or affect patient management …”

• Highest documented level of specificity


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Outpatient Coding Guidance: Current Procedural Terminology (CPT)

• Published by AMA

• Documentation guidance mainly in Evaluation and Management (E/M) section

• 3 key components

– Medical decision‐making, history, examination

• 4 contributory components

– Nature of presenting problem, counseling, coordination of care, time

• Medical decision‐making

• Major E/M revisions proposed

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Outpatient Coding Guidance: Documentation Guidelines for Evaluation and Management Services (DG)

• Jointly published by AMA and CMS• 1995 and 1997 versions• “Assessment, clinical impression, or diagnosis should be

documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation.”

• “For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as ‘possible’, ‘probable’, or ‘rule out’ diagnoses.”– Note difference between OGCR IV.H, Uncertain Diagnosis

• “Treatment includes wide range of management options including patient instructions, nursing instructions, therapies and medications.”


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Thank you. Questions?

Karen Newhouser – [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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Considerations of Compliance

Laurie Prescott, RN‐MSN, CCDS, CDIP, CRCDirector, CDI EducationACDIS


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AHIMA/ACDIS Guidelines for Achieving an Effective Query Practice

• Published 2013, updated 2016

• Update expected 2018

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Query Compliance

• All professionals regardless of licensure, credentials, or background are expected to follow the query guidelines promulgated in this Position Paper

• Queries must not contain any information about their impact on reimbursement

• Should not lead the provider to a specific answer

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No Indicators = No Query

• Whether inpatient or outpatient, all queries (no matter the format) should contain clinical indicators to support why the query was initiated

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Sourcing Clinical Indicators

• In the outpatient setting, not all clinical indicators are available for review during a particular visit or encounter.

• Some laboratory tests are performed outside of the face‐to‐face encounter, possibly prior to the visit. As a result, the outpatient CDI team may need to reference these labs within the query to support why further clarification was initiated.

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Formatting Queries: Multiple‐Choice

• Open‐ended, multiple‐choice, and “yes/no” query formats are acceptable in the outpatient setting. Multiple‐choice query formats should always include “clinically significant and reasonable options as supported by clinical indicators in the health record.”

• Additional options such as “clinically undetermined” and “other” should be included in multiple‐choice query formats so that providers can add free text if the options provided are not applicable.

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Formatting Queries: Yes/No

• A “yes/no” query should not be used in circumstances where only clinical indicators of a condition are present and the condition/diagnosis has not been documented in the medical record. New diagnoses cannot be achieved with a “yes/no” query; for this purpose, an open‐ended or multiple‐choice query format should be used.


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Other Compliance Concerns

• Verbal query = written query

• Policies related to query retention– Archived vs. permanent record

– What to do with unanswered queries

• Escalation process

• No sticky‐note queries

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Compliance & Clinical Validation

• The 2017 OIG Work Plan identified review of MA plan documentation to support clinical validity of diagnoses that impact risk adjustment as a priority– RADV audits

• Diagnoses should only be reported if they meet the UHDDS definition of a reportable diagnosis – We should not query to obtain diagnoses that do not meet this criteria

– A strong query process working to obtain clinically validated diagnosis with supportive documentation of treatment will support compliant and reliable coding practice


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Clinical IndicatorsClinical Validation

• Use evidence‐based clinical practice guidelines (EBCP)

EBCP provides a reference to determine if the clinical indicators, management, evaluation, and treatment for a diagnosis are present. As noted, diagnoses must be supported by clinical indicators in the health record, but this evidence is often supported by, and derived from, the body of the record. If that is the case, the physician does not need to re‐document this evidence in the assessment/plan if it is present elsewhere.

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Laurie Prescott – [email protected]



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Managing the Problem List

Jessica M. Vaughn, MSN, RN, CCDSManager, Clinical Documentation ExcellenceWake Forest Baptist Medical Center Winston‐Salem, NC

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The Problem List

• Originally created as a peer‐to‐peer communication tool to guide patient care

• With the inception of the EHR, became part of the meaningful use program

• Currently aids in the development of outpatient queries


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The Problem List Is a Problem

• What should be placed on the problem list?

–Many disagree on the diagnoses that should be placed on the problem list

• Which problem list is the official one?

– The structure of the Problem List varies widely across organizations

• Who is responsible for the problem list?

– It is typically up to the provider to maintain problem list integrity

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According to CMS, “The Meaningful Use Program required the problem list to include all past and existing diagnoses, pathophysiological states, abnormal physical signs and laboratory findings, disabilities, and unusual conditions.”Department of Health and Human Services, Centers for Medicare and Medicaid Services (2010, July 28). Medicare and Medicaid programs; electronic health record incentive program, final rule.

AHIMA defined the problem list as “A compilation of clinically relevant physical and diagnostic concerns, procedures, and psychosocial and cultural issues that may affect the health status and care of patients.”AHIMA (2008). Best practices for problem lists in an EHR. Journal of AHIMA, 79(1), 73–77.


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How Can CDI Help?

• Provider education

– Chronic problems should remain on the problem list!

– If included on the claim, then it must be documented as evaluated and/or treated, according to coding guidelines

– If no longer relevant, then a problem should be removed/resolved

• Provider queries

– Does the documentation support the diagnosis(es) listed?

– Is there delineation between current status and history‐of only?

– Are problems up‐to‐date?


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Problem List Query Examples

Dear Provider,

Asthma was added to this patient’s problem list following her visit today. Would you please document how this diagnosis was addressed or managed? Thank you.

Susan, CDI Specialist

Dear Provider,

Documentation of “breast cancer/status post radiation” was noted following the patient’s annual visit. Would you please add to the notes the laterality of breast, the specific quadrant, and if the cancer has been completely eradicated or is still under active treatment? Thank you.

Susan, CDI Specialist

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The Standards Haven’t Changed

• The standard for query in all settings is whether the condition is still being treated or is affecting the patient’s condition

– Coding Clinic does not specify whether a CDI specialist can or cannot look at previous encounters, but … [diagnoses may] need to be queried … in order to obtain confirmation and validity

• CDI specialists may review previous encounters for supporting clinical indicators for query based upon:

– Current signs and symptoms

– Current medications

– Recent treatments

• Queries may be prospective, concurrent, or retrospective depending on setting and individual organizational processes

• Developing organization‐specific policies for outpatient CDI queries is strongly recommended!


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The Wake Way

• EDUCATE!

• EDUCATION!

• Strong emphasis on …

EDUCATING!

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The Wake Way

• Current state

– Our CDI specialists do not change the problem list, but they do query providers as appropriate

– We recommend the provider keep the problem list updated

– We have HCC/risk adjustment tools that are based upon problem list diagnoses

• Future state

– Optimizing EHR across the continuum

– Delegated clinic‐based personnel to “tee up” diagnoses at the point of care


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Jessica Vaughn – [email protected]


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Use of Prior Information

Deanne Wilk, BSN, RN, CCDS, CCSManager, CDIPenn State HealthHershey, PA


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Parameters of Visit

• ACDIS recommends implementing a strong policy and procedure for the outpatient CDI team that addresses the parameters of an appropriate visit or encounter

According to Guidelines for Achieving a Compliant Query Practice, “clinical indicators should be derived from the specific medical record under review and the unique episode of care. Clinical indicators supporting the query may include elements from the entire medical record, such as diagnostic findings and provider impressions.” However, in the outpatient setting, not all clinical indicators are available for review during a particular visit or encounter. For example, some laboratory tests are performed outside of the face‐to‐face encounter, possibly prior to the visit. As a result, the outpatient CDI team may need to reference these labs within the query to support why further clarification was initiated.

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Previous Encounters

CDI specialists may encounter diagnoses within the problem list or history whose continued relevance is in doubt.

• CDI specialists are faced with the dilemma of reviewing previous encounters to learn more about these diagnoses.

• With the proliferation of EHRs, CDI specialists can now search previous encounters for conditions that may have been lost in the paper shuffle of years past. But is this practice acceptable?


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Coding Clinic for ICD‐9‐CM, Third Quarter 2013

Coding Clinic for ICD‐9‐CM, Third Quarter 2013, offers the following guidance:

Question: Is there a guideline or rule that indicates that you should only use the medical record documentation for that specific visit/admission for diagnosis coding purposes? Does each visit or admission stand alone? Would the coder go back to previous encounter records to assist in the coding of a current visit or admission?

Answer: Documentation for the current encounter should clearly reflect those diagnoses that are current and relevant for that encounter. Conditions documented on previous encounters may not be clinically relevant on the current encounter. The physician is responsible for diagnosing and documenting all relevant conditions. A patient’s historical problem list is not necessarily the same for every encounter/visit. It is the physician’s responsibility to determine the diagnoses applicable to the current encounter and document in the patient’s record. When reporting recurring conditions and the recurring condition is still valid for the outpatient encounter or inpatient admission, the recurring condition should be documented in the medical record with each encounter/admission. However, if the condition is not documented in the current health record, it would be inappropriate to go back to previous encounters to retrieve a diagnosis without physician confirmation.

Coding Clinic does not specify whether a CDI specialist can or cannot look at previous encounters, but notes that if a condition is carried over from a previous encounter, it would need to be queried to the provider in order to obtain confirmation and validity.

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Chronic Conditions and HCCs

• Just as physicians review the previous visit, CDI specialists may review previous visits in order to advocate for patients and ensure continuity of care.

• If a patient has a history of diabetic neuropathy, retinopathy, and seizures, CDI specialists must ensure that future caregivers have this same specific information versus seeing a nonspecific “DM2” written in the patient’s chart.

• The standard for query in all settings is whether the condition is still being treated or affecting the patient’s condition.

• Chronic conditions are those conditions most often reviewed for HCC reporting, and they often are still affecting the patient.

• CDI specialists must therefore review previous encounters in order to determine clinical relevance based on current signs and symptoms, medications, and recent treatments.

• Lacking authoritative coding guidance, ACDIS recommends that each facility develop its own policy on how far back it will review prior records and follow that policy in a consistent manner.


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Query on Previous Conditions

When reviewing previous encounters to obtain a complete history and accurateportrayal of patients, CDI specialists must query the provider appropriately. It isleading to introduce a diagnosis to the provider in a query without previous clinicalindication. The following is an example of a compliant prospective query in which theCDI specialist reviewed the record prior to the patient’s arrival:

Dear Physician,Your patient, Mr. Jones, has a past medical history of CAD, CHF, andCOPD, as noted on his previous office visit. Current medications includealbuterol, nitroglycerin PRN, and Lasix. Please review this encounter andthese conditions for relevancy and document within Mr. Jones’ upcomingappointment if these are still relevant, and please provide clinical support ofhow they are affecting his care and/or if these conditions are being managed.

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Query in Practice

• A previous encounter policy and procedure will depend on your CDI program goals and objectives for your organization– HCCs

– CMS Bundled Payment Programs

– Severity, clarity, quality, and acuity

– Electronic health record capabilities

– Type of program:

• Pre‐visit– Written query

– Most opportune time to capture pre‐visit data for inclusion

• Concurrent – Verbal query

• Retrospective – Audit and educate

– Great opportunity, with a focused audience, to teach on pre‐visit data and impact


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Deanne Wilk – [email protected]



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