CDIP Virtual Exam Prep: Domain 3

Record Review and Document Clarification

Objectives
• Accurately write effective and compliant
queries
• Review the record review process
• Examine the many areas to be reviewed in the
record
Domain 3 Overview
• Domain 3: Record Review & Document
Clarification
– 14 Subsections in this domain
– Approximately 39 questions of the total 140

3
Domain 3 Topics
1. Identify opportunities for documentation
improvement by ensuring that diagnoses and
procedures are documented to the highest
level of specificity
2. Query providers in an ethical manner to
avoid potential fraud and/or compliance
issues
Domain 3 Topics (continued)
3. Formulate queries to providers to clarify
conflicting diagnoses
4. Ensure provider query response is
documented in the medical record
5. Formulate queries to providers to clarify the
clinical significance of abnormal findings
identified in the record
Domain 3 Topics (continued)
6. Track responses to queries and interact with
providers to obtain query responses
7. Interact with providers to clarify POA
8. Identify post-discharge query opportunities
that will affect SOI, ROM and ultimately, case
weight
Domain 3 Topics (continued)
9. Collaborate with the case management and
utilization review staff to affect change in
documentation
10. Interact with providers to clarify HAC
11. Interact with providers to clarify the
documentation of core measures
12. Interact with providers to clarify PSI
Domain 3 Topics (continued)
13. Determine facility requirements for
documentation of query responses in the
record to establish official policy and
procedures related to CDI query activities
14. Develop policies regarding various stages of
the query process and time frames to avoid
compliance risk
Topic 1

IDENTIFY OPPORTUNITIES FOR

DOCUMENTATION IMPROVEMENT BY
ENSURING THAT DIAGNOSES AND
PROCEDURES ARE DOCUMENTED TO
THE HIGHEST LEVEL OF SPECIFICITY
When to Query
• Clinical indicators of a diagnosis but no documentation
of the condition
• Clinical evidence for a higher degree of specificity or
severity
• A cause-and-effect relationship between two
conditions or organism
• An underlying cause when admitted with symptoms
• Only the treatment is documented (without a diagnosis
documented)
• Present on admission (POA) indicator status
• Illegibility of documentation
Diagnosis Specificity
• Diagnoses: more specific description
– Specificity
– Etiology
– Acuity
More Opportunities …
• Site
• Laterality
• Type
• Stage
Procedure Specificity
• Procedures: more specificity
– Section (Medical and Surgical)
– Body System (Respiratory)
– Root Operation (Excision)
– Body Part (Bronchus)
– Approach (Bronchoscopy)
– Device (Stent)
– Qualifier (Biopsy)
Additional Learning Activity
• Review the ICD-10-CM and ICD-10-PCS code
sets to identify areas of necessary specificity.
• Examples:
– Skin ulcers
– Fractures
– Procedures
Topic 2

QUERY PROVIDERS IN AN ETHICAL

MANNER TO AVOID POTENTIAL FRAUD
AND/OR COMPLIANCE ISSUES
Writing Ethical Queries
• Ethical Query Practices
• Review information on the AHIMA website

www.ahima.org/topics/cdi
Query Example
• Obtunded patient admitted with 3-day history of
nausea and vomiting. CXR revealed right lower lobe
pneumonia. Clindamycin ordered.
• Unethical Query (Leading):
– Is the patient’s pneumonia due to aspiration?
• Ethical Query (Non-leading):
– Can the etiology of the patient’s pneumonia be further
specified? It is noted in the admitting H&P this obtunded
patient had a history of nausea and vomiting prior to admission
to the hospital and is treated with Clindamycin for RLL
pneumonia. Based on the above, can the etiology of the
pneumonia be further specified? If so, please document the
type/etiology of the pneumonia in the progress notes.
Additional Learning Activity
• Review the AHIMA Practice Brief “Guidelines
for Achieving a Compliant Query Practice
(2016 Update)” at
http://library.ahima.org/PB/QueryCompliance#.WNGefU3rvm
Q
Topic 3

FORMULATE QUERIES TO PROVIDERS

TO CLARIFY CONFLICTING DIAGNOSES
Handling Conflicting Diagnoses
• Identify the conflicting diagnoses for the
provider
• Provide where (what report) the conflicting
information is located
• Provide clinical indicators to assist provider in
determining the diagnosis
• Who makes the final determination?
Additional Learning Activity
• Review Chapter 1 of the Pamela Hess book
(see reference at the end of this webinar) on
Criteria for High-Quality Clinical
Documentation
Topic 4

ENSURE PROVIDER QUERY RESPONSE IS

DOCUMENTED IN THE MEDICAL
RECORD
Where is the Query Stored?
• Review state requirements for query retention
• Maintain query in medical record
• Document in the Progress Notes or dictated
reports
Additional Learning Activity
• Review the AHIMA CDI Toolkit for additional
information on Query Management.
http://library.ahima.org/Toolkit/CDI#.WNGe8U3rvmQ
Topic 5

FORMULATE QUERIES TO PROVIDERS

TO CLARIFY THE CLINICAL SIGNIFICANCE
OF ABNORMAL FINDINGS IDENTIFIED
IN THE RECORD
 7 Criteria of High-Quality
Documentation
Criteria Example/Description
Legibility Required under all government and regulatory agencies
Reliability Treatment provided without documentation of condition being treated
Precision No specific diagnosis documented, more specific diagnosis appears to
be supported
Completeness Abnormal test results without documentation for clinical significance
(Joint Commission requirement)
Consistency Disagreement between two or more treating physicians without
obvious resolution of the conflicting documentation upon discharge
Clarity Vague or ambiguous documentation, especially in the case of symptom
principal diagnosis
Timeliness Documentation that is not complete within the guidelines set by the
facility, CMS, state, Joint Commission, and other regulatory agencies
Formulate Queries
• Provide information where diagnosis
documentation written
– Abnormal lab findings
– Abnormal radiology findings
– Other
Query Layout
• Query layout
– Clinical indicators/diagnoses
– Location of information
• Provide response area
– Check boxes
– Area to write response
– POA
Query Example
• Documentation: Laboratory finding of serum
sodium of 120 mmol/L and the attending
physician documents hypernatremia in the
final diagnostic statement.
• Query: Please review the laboratory section of
the present record to confirm your discharge
diagnosis of hypernatremia. Laboratory
findings indicate a serum sodium of 120
mmol/L.
Query Format
• Include the following:
– Patient name
– Admission date / date of service
– Health record number
– Account number
– Date of query
– Name/contact information of CDS/Coder
– Statement of the issue
Query Format (continued)
• Statement of the Issue:
– Written as a question
– Clinical indicators from the chart
– Ask the practitioner to make a clinical interpretation of the
facts in the chart
– Query format should not sound presumptive, directing,
prodding, probing or as though the practitioner is being
led to a diagnosis
Yes/No Queries
• In general, queries should not be designed to ask questions
that result in a yes/no response
• Exceptions:
– POA queries when a diagnosis has already been documented
– Substantiating or further specifying a diagnosis that is already present
in the health record (i.e., findings in pathology, radiology, etc.) with
interpretation by a physician
– Establishing a cause and effect relationship between documented
conditions, such as manifestation/etiology, complications, and
conditions/diagnostic findings (e.g., HTN and CHF, diabetes and CKD)
– Resolving conflicting documentation from multiple practitioners
Multiple Choice Queries
• Make these types of queries as open-ended as possible
• The clinically reasonable choices should be listed
• Also include:
– Other explanation of clinical findings
– Unable to Determine
– Findings of No Clinical Significance
Avoid Leading Queries
• A query is never intended to lead the provider
to one desired outcome.
• The query must provide reasonable clinically
supported options, include clinical indicators.
• These must include the option that no
additional documentation or clarification can
be provided.
Avoid Adding New Information
• Introduction of new information not
previously document is inappropriate
• If this diagnosis was not documented in the
current admission and is not affecting the
patient’s care, it does not meet the definition
of secondary diagnosis
• Querying for this new information, which does
not meet coding and reporting requirements,
is inappropriate
When Not to Query
• Do not query when the
benefit is strictly for
reimbursement, there
should also be
documentation
improvement involved
• When the facility’s
policy and procedures
for CDI state not to
query a provider in
certain situations
When Not to Query
• Clinically insignificant
findings or irrelevant
information shouldn’t
result in a query
• Do not query based on
information from a
previous visit, that is
not documented or
referred to in the
present visit
Topic 6

TRACK RESPONSES TO QUERIES AND

INTERACT WITH PROVIDERS TO OBTAIN
QUERY RESPONSES
How to Track?
• Manual
• Automated
– Spreadsheet
– Other program
Example Query Response Report
Example Query Response Report
Topic 7

INTERACT WITH PROVIDERS TO CLARIFY

POA
Present on Admission (POA)
• POA indicators
– Y = Yes
– N = No
– U = Unknown
– W = Clinically undetermined
• Importance of POA
• Impact of POA
Additional Learning Activity
• Review the AHIMA Practice Brief “Guidelines
for Achieving a Compliant Query Practice
(2016 Update)” at
http://library.ahima.org/PB/QueryCompliance#.WNGfYE3rvm
Q
• Review the POA guidelines found in the ICD-
10-CM Official Coding Guidelines.
Topic 8

IDENTIFY POST-DISCHARGE QUERY

OPPORTUNITIES THAT WILL AFFECT SOI,
ROM AND ULTIMATELY, CASE WEIGHT
Post-Discharge Queries
• Queries that impact SOI & ROM:
– How can these opportunities be captured pre-
discharge?
– Communication between Clinical Documentation
Specialist and Coder
Topic 9

COLLABORATE WITH THE CASE

MANAGEMENT AND UTILIZATION
REVIEW STAFF TO AFFECT CHANGE IN
DOCUMENTATION
Collaboration
• Education opportunities at Case Management
meetings
– Length of stay (LOS)
– How documentation affects LOS
Collaboration
• Attend Utilization Review meetings
– Share impact of CDI program
– Share documentation concerns/suggestions
Topic 10

INTERACT WITH PROVIDERS TO

CLARIFY HAC
Hospital Acquired Conditions (HACs)
1. Foreign object retained after surgery
2. Air embolism
3. Blood incompatibility
4. Pressure ulcer stages III and IV
5. Falls and Trauma (fracture, dislocation, intracranial injury, crushing
injury, burn, other injuries)
6. Catheter-associated UTI
7. Vascular catheter-associated infection
8. Manifestations of poor glycemic control
9. Surgical site infection, mediastinitis, following CABG
10. Surgical site infection following certain orthopedic procedures
11. Surgical site infection following bariatric surgery for obesity
12. Surgical site infection following cardiac implantable electronic device
13. Deep vein thrombosis and pulmonary embolism following certain
orthopedic procedures
14. Iatrogenic pneumothorax with venous catheterization
Additional Learning Activity
• Learn more about HACs at the CMS website at
https://www.cms.gov/medicare/medicare-fee-for-service-
payment/hospitalacqcond/hospital-acquired_conditions.html
Topic 11

INTERACT WITH PROVIDERS TO CLARIFY

THE DOCUMENTATION OF CORE
MEASURES
What Are Core Measures?
• CMS-recommended core measures in the inpatient setting
• Adult recommended core measures (2014):
1. Controlling high blood pressure
2. Use of high-risk medication in the elderly
3. Preventive care and screening – tobacco use
4. Use of imaging studies for low back pain
5. Preventive care and screening – clinical depression
6. Documentation of current medications
7. Preventive care and screening – BMI
8. Closing the referral loop – receipt of specialist report
9. Functional status assessment for complex chronic conditions
Working with Core Measure Staff
• Work with Core Measure staff
• Understand elements that CDS may see during
chart review
• Notify Core Measure staff of potential patients
who meet requirements
Additional Learning Activity
• Learn more about Core Measures at the CMS
website at https://www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/Recommended_
Core_Set.html
Topic 12

INTERACT WITH PROVIDERS TO

CLARIFY PSI
Patient Safety Indicators
• Agency for Healthcare Research & Quality
(AHRQ)
• What are Patient Safety Indicators (PSIs)?
– Improve safety of inpatient care
• How can the CDS work with and inform
providers about PSI?
Additional Learning Activity
• Learn more about PSIs at the AHRQ website at
http://www.qualityindicators.ahrq.gov/modules/psi_overview
.aspx
Topic 13

DETERMINE FACILITY REQUIREMENTS

FOR DOCUMENTATION OF QUERY
RESPONSES IN THE RECORD TO
ESTABLISH OFFICIAL POLICY AND
PROCEDURES RELATED TO CDI QUERY
ACTIVITIES
Query Policies & Procedures
• Policy and Procedures
– Query Response in record
• Queries retained in record
• Queries maintained elsewhere
Topic 14

DEVELOP POLICIES REGARDING

VARIOUS STAGES OF THE QUERY
PROCESS AND TIME FRAMES TO AVOID
COMPLIANCE RISK
Query Process Policies
• Concurrent Queries
– Query response time frame
• Retrospective Queries
– Query response time frame
• Process for providing queries to the providers
Summary of Topics
• Identify opportunities for documentation
improvement
• Query providers in an ethical manner
• Formulate queries
• Ensure provider query response is
documented
Summary of Topics
• Formulate queries to providers to clarify
abnormal findings
• Track responses to queries
• Interact with providers to clarify POA
• Identify post-discharge query opportunities
• Collaborate with case management and
utilization review staff
Summary of Topics
• Interact with providers to clarify HAC
• Interact with providers to clarify
documentation of core measures
• Interact with providers to clarify PSI
• Determine facility requirements for
documentation of query responses
• Develop policies regarding various stages of
the query process
ADDITIONAL QUERY EXAMPLES
Example 1
The patient is a 44-year-old male who started having
abdominal pain the day before yesterday. Subsequently
he had diarrhea. He had 4 episodes of diarrhea last
night and then 4 episodes in the morning. The stools
have turned to fairly frank blood. Also the abdominal
pain got worse, and he said he felt dizzy when he stood
up. Patient admitted for treatment of dehydration.
Patient has frank blood coming out from his bowels.
Stool culture and sensitivity revealed Salmonella.
Physician documented that the abdominal pain,
diarrhea, and bleeding were due to gastroenteritis.
Patient put on Levaquin IV and also rehydrated.
Query Opportunities
• Type and acuity of Gastroenteritis
• Underlying organism
• GI bleed
Creating the Compliant Query
44 y/o male admitted with abdominal pain, diarrhea, and
frank red blood all due to gastroenteritis. A stool culture
revealed sensitivity to Salmonella. Treated with
rehydration and IV antibiotics. Can the type and acuity of
the gastroenteritis be further specified?
•Infectious Gastroenteritis (if so please specify the
organism if known?
•Non-infectious Gastroenteritis (if so please specify
the underlying cause if known)
•Other explanation of clinical findings____________
•Unable to determine
•Findings of no clinical significance
Creating the Compliant Query
44 y/o male admitted with abdominal pain, diarrhea, and frank
red blood all due to gastroenteritis. A stool culture revealed
sensitivity to Salmonella. Treated with rehydration and IV
antibiotics. Can the frank red blood be further specified?
•Melena
•Upper GI Bleed (if so please specify if it is related or
unrelated to the Gastroenteritis)
•Lower GI Bleed (if so please specify if it is related or
unrelated to the Gastroenteritis)
•Other explanation of clinical findings______________
•Unable to determine
•Findings of no clinical significance
Example 2
This 80-year-old female patient was admitted with fever of
102 Fahrenheit, malaise, WBC 15,000, pulse 120. The
patient has a chronic indwelling Foley catheter. A urinalysis
was performed and showed bacteria more than
100,000/mL. Urine culture, Escherichia coli growth
documented as E. coli urinary tract infection (UTI). Pt has a
history of COPD with audible wheeze and pulse oximeter
noted as 87, supplemental oxygen is ordered at 2l via n/c.
On day 2 the physician documents exacerbation of chronic
obstructive pulmonary disease (COPD) and orders nebulizer
treatments. Patient is also on current medication therapy
for hypertension and arteriosclerotic heart disease(ASHD)
which are both documented within the H&P.
Query Opportunities
• Sepsis
• UTI relationship with Foley
• Type of hypertension
• COPD Exacerbation POA
or developed after admission
Creating the Compliant Query-Sepsis
80-year-old female patient was admitted with fever of 102 Fahrenheit, malaise,
WBC 15,000, pulse 120. The patient has a chronic indwelling Foley catheter. A
urinalysis was performed and showed bacteria more than 100,000/mL. Urine
culture, Escherichia coli growth documented as E. coli urinary tract infection
(UTI). Can a diagnosis be provided to provide further specificity?
•Sepsis (if so please specify if this was present on admission or developed
after admission and the underlying cause and organism if known.
•SIRS without the presence of Sepsis (If so please specify the underlying
cause)
•Other explanation of clinical findings___________________________
•Unable to determine
•Findings of no clinical significance
Creating the Compliant Query-
UTI/Foley Relationship
80-year-old female patient was admitted with fever of 102 Fahrenheit, malaise,
WBC 15,000, pulse 120. The patient has a chronic indwelling Foley catheter. A
urinalysis was performed and showed bacteria more than 100,000/mL. Urine
culture, Escherichia coli growth documented as E. coli urinary tract infection
(UTI). Can the relationship between the indwelling Foley catheter and the UTI
be further specified?
•UTI related to chronic indwelling Foley catheter
•UTI unrelated to chronic indwelling Foley catheter
•Other explanation of clinical findings_________________________
•Unable to determine
•Findings of no clinical significance
Creating the Compliant Query-Type of
Hypertension
80-year-old female patient was admitted with an E. coli urinary tract
infection (UTI). The patient also has hypertension and arteriosclerotic
heart disease(ASHD) documented in the H&P and home medication
were resumed. Can the relationship between the ASHD and
hypertension be further specified?
•Hypertensive Heart Disease (Hypertension secondary to ASHD)
•Essential Hypertension (Hypertension unrelated to ASHD)
•Other explanation of clinical findings__________________
•Unable to determine
•Findings of no clinical significance
Creating the Compliant Query-POA
COPD Exacerbation
80-year-old female patient was admitted with an E. coli urinary tract
infection (UTI). Pt has a history of COPD with audible wheeze and pulse
oximeter noted as 87, supplemental oxygen is ordered at 2l via n/c. On
day 2 exacerbation of chronic obstructive pulmonary disease (COPD) is
documented and nebulizer treatments are ordered . Can it be further
specified if the COPD exacerbation was present on admission of
developed after admission?
•COPD exacerbation was present on admission
•COPD exacerbation developed after admission
•Other explanation of clinical findings______________________
•Unable to determine
•Findings of no clinical significance
Example 3
• This is a 47-year-old female admitted to the hospital
for a scheduled total abdominal hysterectomy and
bilateral salpingo-oophorectomy due to submucous
leiomyoma of the uterus. The patient also has
extensive endometriosis of the uterus, ovaries, and
pelvic peritoneum. On the day of admission the patient
was taken to surgery and, in addition to the scheduled
procedure, lysis of extensive pelvic adhesions was also
carried out. In the process of removing the adhesions,
the physician accidently punctured the small bowel.
This small puncture was quickly repaired. The operative
report documented loss of 1,500 ml of blood during
surgery.
Query Opportunities
• Complication or an expected outcome to the
procedure
Creating the Compliant Query

47-year-old female admitted to the hospital for a scheduled total abdominal

hysterectomy and bilateral salpingo-oophorectomy due to submucous leiomyoma of
the uterus. The patient also has extensive endometriosis of the uterus, ovaries, and
pelvic peritoneum. The patient was taken to surgery and, in addition to the scheduled
procedure, lysis of extensive pelvic adhesions was also carried out. It is noted that the
small bowel was accidently punctured. The operative report documented loss of 1,500
ml of blood during surgery. Please further specify if the small bowel puncture was a
complication or the procedure or an expected outcome of the procedure?
•Small Bowel puncture was a complication of the procedure
•Small Bowel puncture was an expected outcome of the procedure due to the
extensive pelvic adhesions
•Other explanation of clinical findings____________________________
•Unable to determine
•Findings of no clinical significance
Example 4
The patient is an 80-year-old white female with a known
history of carcinoma of the breast. The patient was
admitted because of increasing shortness of breath. Chest-
x-ray as noted by radiologist is consistent with pulmonary
mets. The patient was treated previously with
chemotherapy. Patient states has not been able to eat or
drink due to severe SOB.
PMH: COPD, smoked cigarettes for 20 years, HTN.
Laboratory results include BUN 37, creatinine ranging from
2.3 on admission to 1.1 on day 3, sodium 141, and
potassium 4.5.
Physician progress note, hydrate for pre-renal azotemia,
breast ca, 02 3 liters, nebulizer rx
Query Opportunities
• Pulmonary Mets
• Renal Failure
• COPD exacerbation
Creating the Compliant Query-
Pulmonary Mets
This 80-year-old white female with a known history of
carcinoma of the breast was admitted because of increasing
shortness of breath. Chest-x-ray as noted by radiologist is
consistent with pulmonary mets. The patient was treated
previously with chemotherapy. The progress note documents
hydrate for pre-renal azotemia, breast ca, 02 3 liters,
nebulizer rx. Can you further specify if you agree or disagree
with the Chest x-ray finding of pulmonary mets?
•Agree with the diagnosis of pulmonary mets
•Disagree with the diagnosis of pulmonary mets
•Other explanation of clinical findings____________
•Unable to determine
•Findings of no clinical significance
Creating the Compliant Query-
Abnormal Renal Functions

This 80-year-old white female with a known history of carcinoma of the

breast was admitted because of increasing shortness of breath.
Laboratory results include BUN 37, creatinine ranging from 2.3 on
admission to 1.1 on day 3, sodium 141, and potassium 4.5. Progress note
documents hydrate for pre-renal azotemia, breast ca, 02 3 liters,
nebulizer rx. Can a diagnosis be provided to support the clinical findings?
•Acute Renal Failure
•Acute Renal Insufficiency
•Chronic Kidney Disease (if so please specify the stage if known)
•Other explanation of clinical findings____________________
•Unable to determine
•Findings of no clinical significance
Creating the Compliant Query-COPD
exacerbation

This 80-year-old white female with a known history of carcinoma of the

breast was admitted because of increasing shortness of breath. Patient
states has not been able to eat or drink due to severe SOB. PMH: COPD,
smoked cigarettes for 20 years, Progress note documents hydrate for
pre-renal azotemia, breast ca, 02 3 liters, nebulizer rx. Can the diagnosis
of COPD be further specified?
•COPD exacerbation
•COPD without exacerbation
•Other explanation of clinical findings_______________________
•Unable to determine
•Findings of no clinical significance
AHIMA CDIP Exam Prep Resources
• Easterling, S. CDIP Exam Preparation. AHIMA
Press: 2016.
https://my.ahima.org/store/product?id=63381
• Hess, P. Clinical Documentation Improvement:
Principles and Practice. AHIMA Press: 2015.
https://my.ahima.org/store/product?id=62223
• Online CDIP Exam Prep Series.
http://www.ahima.org/education/onlineed/Pro
grams/examprep
• Online CDIP Practice Exam (84 questions).
https://my.ahima.org/store/product?id=62474