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April 11, 2005

Physician Queries: Don’t Ask … or Do?
By Robert Gold, MD
For The Record
Vol. 18 No. 8 P. 22

When is it appropriate for coders to question physicians about documentation?

In the past two years, “authorities” have put fear into coding professionals regarding what they consider “kosher” queries. The major issue seems to be “Thou shalt not lead the physician.” This has been interpreted in many ways.

AHA Coding Clinic for ICD-9-CM has published many citations about situations in which the coder must ask the physician for additional information or clarification. Since the early 1990s, consultants have gotten hospitals into trouble by urging assignments based on their interpretation of “incontrovertible evidence” in the chart. The crackdowns led to the Payment Error Prevention Program (PEPP), which changed their tactics to “leading” the physician down the garden path.

For example, with every patient who has certain risk factors listed in Coding Clinic’s third quarter 1998 article about gram-negative pneumonia, consultants urge the physician to document that he or she is treating gram-negative pneumonia regardless of the likelihood that it exists at all. They beg the question of documenting aspiration pneumonia for every nursing home patient who has had a stroke. They ask for documentation of acute respiratory failure regardless of the patient’s clinical presentation just because gases may be low. They ask for documentation of sepsis every time the physician writes “urosepsis” even though the patient has stable vital signs and is documented to be in no acute distress. And doctors do it because they are told it’s the right thing to do “according to Medicare.”

In other words, when there is no clinical supportive information in the record that the condition exists—other than referring to Coding Clinic citations that are only there as explanations—that’s leading.

So when can you ask? And what can you ask? And whom do you ask?

Recently, some professionals are saying the diagnosis must be confirmed in the discharge summary before it can be considered valid. However, that’s incorrect.

When a patient, admitted and treated by an internist, responds to treatment and something happens—a fall, an acute abdomen, something that leads to the need for surgical intervention unrelated to the original issues—the patient may well be transferred to a surgeon and discharged from that service.

Now, how many surgeons go through the machinations of reciting all the medical diagnoses that have been chronic stable conditions or were acute conditions earlier? Not many. So the physician’s discharge summary will contain something like: “Patient transferred for acute abdomen. Diagnosis determined to be acute gall bladder. Cholecystectomy performed. Benign postoperative course. Discharged. Return two weeks.”

So what happens to the other diagnoses? The reason the patient was admitted in the first place? Are you going to say that none of these can be coded?

Which physician is to be the final authority for codes? Coding Clinic First Quarter 2004 tells us:

Question:
Please provide clarification regarding the appropriateness of code assignments based on the documentation in the medical record by a physician other than the attending physician. Previously published Coding Clinic advice has allowed using documentation from the anesthesia report. Our coders have interpreted that the lack of contrary documentation from the attending can be perceived as concurrence with the anesthesiologist. We have recently been advised that we cannot use a consultant’s note without “confirmation” from the attending physician. Our coders tell us it is operationally impossible to confirm every single diagnosis or condition the consultant writes. Of course, if there is conflicting information, we will query the attending physician for clarification. Can you comment on whether our interpretation of coding instructions is correct?

Answer:
Code assignment may be based on other physician (ie, consultants, residents, anesthesiologist) documentation as long as there is no conflicting information from the attending physician. Medical record documentation from any physician involved in the care and treatment of the patient, including documentation by consulting physicians, is appropriate for the basis of code assignment. A physician query is not necessary if a physician involved in the patient’s care and treatment, including consulting physicians, has documented a diagnosis and there is no conflicting documentation from another physician. If documentation from different physicians conflicts, seek clarification from the attending physician as he or she is ultimately responsible for the final diagnosis. This information is consistent with the AHIMA documentation guidelines.

So this is a case when seeking clarification is not required.

And in what part of the medical record can you find the diagnoses and assign codes? Coding Clinic Second Quarter 2000 says:

Question:
I am requesting clarification of what appears to be conflicting direction between an AHIMA Practice Brief and the Official Coding Guidelines. The AHIMA Practice Brief on Data Quality states that coding professionals may “assign and report codes, without physician consultation, to diagnoses and procedures not stated in the physician’s final diagnosis only if these diagnoses and procedures are specifically documented by the physician in the body of the medical record and this documentation is clear and consistent.”

The Official Coding Guidelines ODX (other diagnosis) #2 states, “When the physician has documented what appears to be a current diagnosis in the body of the record, but has not included the diagnosis in the final diagnostic statement, the physician should be asked whether the diagnosis should be added.”

Answer:
The two statements listed above are not inconsistent, but reinforce each other. When the documentation in the medical record is clear and consistent, coders may assign and report codes. If there is evidence of a diagnosis within the medical record and the coder is uncertain whether it is a valid diagnosis because the documentation is incomplete, vague, or contradictory, it is the coder’s responsibility to query the attending physician to determine whether this diagnosis should be included in the final diagnostic statement. All diagnoses should be supported by physician documentation. Documentation is not limited to the face sheet, discharge summary, progress notes, history and physical, or other report designed to capture diagnostic information. This advice refers only to inpatient coding.

Now we can see some areas we don’t have to query.

When must you seek clarification? When clarification is indicated. When something is documented in the record that leads you to have to consider two or more codes such as “Resp F.” The doctor intends to indicate “Respiratory Failure,” but there are four possible permutations of respiratory failure and coders have to choose the right one. So they ask for clarification.

“When you say ‘Resp F’ in this COPD [chronic obstructive pulmonary disease] patient with documented hypoxemia and documented hypercapnia, do you intend to indicate that the patient has:

• acute respiratory failure;

• chronic respiratory failure;

• acute or chronic respiratory failure; or

• postoperative or posttraumatic respiratory failure (in those cases where the situation occurred in the postoperative or posttraumatic period)?”

Then ask, “Please clarify in a dated and signed progress note (if concurrent) or in the discharge summary or in an addendum to the discharge summary. Thank you.”

Some would consider this leading. However, it is not. The physician said something that needs clarification to assign the accurate and specific ICD code. You must get clarification. You have presented all the options and permitted the physician to choose the correct one for the clinical scenario.

Here’s another well-known situation in which there could be two connotations to words that were documented in the medical record. Coders are obliged to seek clarification to find out what the physician intends to have the clinical situation express.

Coding Clinic First Quarter 1988 — the Urosepsis conundrum

Urosepsis: Although the Alphabetic Index assigns urosepsis to urinary tract infection, 599.0, this classification may or may not be what the physician intended. The physician should be asked whether the diagnosis of urosepsis is intended to mean (1) generalized sepsis (septicemia) caused by leakage of urine or toxic urine by-products into the general vascular circulation; or (2) urine contaminated by bacteria, bacterial by-products, or other toxic material but without other findings, 599.0.

By going ahead and asking the physician which definition he or she intends for their patient’s condition, you are not leading. You are seeking clarification because there are two scenarios in which one word can have two connotations.

Here’s another cute one—and it’s only cute if it’s not your grandmother who’s involved. Charcot foot. Put that into your encoder and you get a default code and implication: due to tertiary syphilis. Who’s going to like it when they get a surprise phone call from the Centers for Disease Control and Prevention because they have venereal disease?

In the United States, the No. 1 cause of Charcot foot is diabetes with neurologic manifestations. If there is indication that the patient is diabetic, you are well-served to seek clarification. What does the physician wish to document simply to express what’s truly wrong with this patient?

Sometimes, the physician uses symbols: plusses, minuses, up arrows, down arrows. In the clinical situation, it is incumbent on coders to seek clarification if that “Na” with an up arrow means hypernatremia or something else, such as sodium levels returning to normal. If that “Hb” with a down arrow and a level of 6.8 grams indicate that the transfusion was for anemia, what was the cause of the anemia if that’s indeed what was meant? Does “ETOH” with a plus mean the patient is alcoholic, an alcohol abuser, drinks socially, or had a positive blood alcohol level? There are codes for many of these and no code should be assigned to others.

When there are multiple possible interpretations to what is documented, coders must ask which one the doctor means to denote.

But do not pull things out of thin air. For example:

• A patient with acute exacerbation of COPD who is admitted after treatment in the emergency department is not comfortable. Someone asks, “Would you please write ‘acute respiratory failure’ in the progress notes?” Documentation reads “Patient in no acute distress” and “Respiratory Rate = 16,” and there is no documentation of clinical signs of severe respiratory effort being made.

• A patient has acute abdominal pain, a temperature of 101°, a pulse rate of 100, and an ultrasound that shows gallstones and edema around the gallbladder consistent with acute cholecystitis. Someone asks, “Would you please document ‘sepsis’ in the progress notes?”

• A 74-year-old woman living at home had a cold all last week and now has a temperature elevation and cough that won’t let her sleep, but no other significant illnesses except maybe hypertension. She has a white count of 4,600 with 45% lymphocytes and 4% monocytes and bilateral fluffy infiltrates that the emergency department physician calls “pneumonia” and treats with Rocephin and Zithromax. Someone asks, “Would you please write ‘probable gram-negative pneumonia’ in the progress notes?”

These are examples of pulling stuff out of thin air. They are not the intent of asking the physician for clarification. They represent maximization and are inappropriate.

The following are excerpts from Coding Clinic that express the Cooperative Parties’ outlook on indications to ask for physician clarification. Ask a question when it will help express severity, accuracy, and specificity; differentiate two or more possible code sets; and clarify which one the physician intends for the patient.

Coding Clinic May/June 1984

Not clear whether a listed diagnosis is valid now

Abstract:

The admitting diagnosis is left inguinal hernia. Medical history reveals that the patient was hospitalized two years ago for congestive heart disease. Examination revealed inguinal hernia. X-rays and EKG [electrocardiogram] revealed mild cardiomegaly and chronic atrial fibrillation with occasional PVC [premature ventricular contractions]. Surgery revealed large indirect hernia with smaller direct hernia, numerous adhesions, and sliding hernia. Solid repair was accomplished. On second postoperative day, patient ran a fever and complained of pain in first metatarsal. Swelling of foot, ankle, and leg occurred. The patient had an elevated uric acid level and was treated for gout.

The physician recorded the diagnoses as:

Principal: Hernia inguinal, direct, indirect, sliding left (550.90)

Secondary Diagnosis: Acute gout, left foot (274.0)

Complications: Testicular edema, mild (608.86)

Question:
Should chronic atrial fibrillation, adhesions, and lysis of adhesions be coded, even though the physician did not record them on the discharge summary?

Answer:
Contact the physician regarding documentation and coding of adhesions and lysis of adhesions and ask whether the chronic atrial fibrillation had any effect on the hospital stay or was treated during the hospital stay. Lysis of adhesions can be coded as documented in the operative report. However, the diagnoses should be documented by the physician prior to coding and reporting on any Medicare inpatient services.

Coding Clinic July/August 1984

COPD types

It may be necessary to query the attending physician as to which of the five categories is intended for classification purposes. Ask the physician whether the diagnosis of COPD and chronic bronchitis can be classified as obstructive chronic bronchitis or chronic obstructive emphysematous bronchitis, 491.2.

COPD is often referred to as irreversible airway obstruction associated with chronic bronchitis and/or emphysema. Asthma is referred to as reversible airway obstruction (can be treated to remove the airway obstruction). When both asthma (493.0-493.9) and COPD appear in the same statement of diagnoses, it will be necessary to query the physician as to the type of pulmonary dysfunction involved.

Coding Clinic November/December 1984

Pathologic Fracture

Question:
How does one determine whether a fracture of a vertebra is pathological or traumatic?

Answer:
The best course of action is to ask the attending physician. Otherwise, read the x-ray reports describing the fracture of the vertebra. In [older] patients, especially women, with osteoporosis involving the spine, compression fracture of the vertebral body may occur due to thinning of the cortices or wedging of vertebrae. This would be classified as a pathological fracture. Degeneration of the vertebrae due to osteoarthritis may cause a compression fracture (pathological). Rarefaction of the bone due to other disorders of the spine, as well as malignant neoplasms, may also cause a pathological fracture.

Other various citations include the following:

• Is it congenital or not? Ask the attending physician whether the diagnosis of left parietal venous malformation should be classified as a cerebral venous angioma (228.02) or as a congenital malformation of a cerebral vein (747.81).

• Get more specific with psych codes. Ask the physician to review the subentries under category 296 and the fifth-digit code assignments for the possibility of selecting a more specific clinical subtype of affective disorder.

• Ask for pathogenesis of anemias. Anemia of chronic disease not otherwise specified not further specified is coded 285.9, Anemia unspecified. Where possible, the physician should be asked to further specify the type of anemia, such as iron deficiency anemia associated with cancer, nonautoimmune hemolytic anemia associated with renal failure, and so forth.

• Clarify primary or secondary malignancies. Malignant neoplasms of lymph nodes or glands are presumed to be secondary neoplasms (196.0-196.9) unless the diagnosis states or indicates a malignancy classifiable to categories 200-202. Lymphoma(s) may be benign or malignant. If the physician’s diagnostic statement does not match any subentries under Lymphoma on page 460 in the Alphabetic Index, refer to the pathology report for correlation with entries on page 460 in the Alphabetic Index. Otherwise, ask the responsible physician whether the lymphoma is benign or malignant.

• Clarify the extent of a procedure when there are options. A lumpectomy procedure can be any one of three procedures depending on the extent of the procedure carried out. Read the operative report or ask the surgeon who performed the procedure to determine whether the “lumpectomy” involved is: Local excision of a mass or lesion, 85.21; Quadrant resection of breast, 85.22; or Partial mastectomy, 85.23. A lumpectomy may be performed for benign or malignant tumors.

• Is a postprocedural condition related to (caused by) treatment? In many instances, the cause of the postoperative cystitis or postoperative urinary tract infection is not documented in the medical record, or the exact cause may not be known. When this occurs, the physician should be asked whether the urinary tract infection or cystitis is related to or resulted from the procedure performed.

• Rather than unspecified heart failure, is it congestive heart failure? Acute and chronic heart failure, not otherwise specified, is coded 428.9, Heart failure, unspecified. Before assigning this code, ask the physician whether the diagnosis refers to congestive heart failure, such as a compensated congestive heart failure that has become decompensated. If so, code it to 428.0.

• Clarify etiology of acidosis. Note that code 276.2 has an exclusion note for diabetic acidosis (250.1). If the patient is a diabetic, ask the physician whether the metabolic acidosis is diabetic (250.1) or associated with the dialysis (276.2).

• Can you give us a diagnosis for a nonnamed arrhythmia? Rapid ventricular response rate or slow ventricular response rate usually refers to the EKG interpretation in the diagnostic approach to cardiac arrhythmias. If the physician’s statement of diagnosis is either rapid or slow ventricular response rate without further specification of the diagnostic condition (such as specific type of arrhythmia), do not attempt to code it. Ask the physician to provide further documentation of the diagnostic condition for coding and reporting purposes.

• Is “azotemia” representative of one of the many types of “failure”? Prerenal azotemia, 788.9, postrenal azotemia, 788.9, and azotemia (renal), 790.6, refer to marked elevation of urea nitrogen (and creatine). However, the term azotemia may be used in reference to the presence of acute renal failure, 584.9, or chronic renal failure, 585. The codes for prerenal or postrenal azotemia, 788.9, and azotemia, 790.6, represent symptom and sign findings and are not assigned as principle diagnoses when the cause is known. When the physician documents azotemia, it may be necessary at times for the coder to ask the physician whether the diagnosis of azotemia refers to the presence of acute renal failure or chronic renal failure.

• When faced with “ulcer disease” with a patient on meds, clarify whether the ulcer is still active. Healed peptic ulcers are coded to V12.7, Personal history of diseases of digestive system. Maintenance therapy with Tagamet may indicate controlling peptic acid disease with antacid, 536.8, Dyspepsia and other specified disorders of function of stomach. The physician should be asked whether this is chronic peptic ulcer, 533.7; peptic acid disease, 536.8; or healed ulcer, V12.7.

• Clarify the relationship between hypertension and failure. If there is no cause-and-effect relationship stated, the code assignments are 428.0, Congestive heart failure, plus 401.9, Essential hypertension, unspecified. However, the coder should ask the physician whether the intent is hypertensive heart disease with congestive heart failure, 402.91. This determination is a clinical decision and should be made by the physician.

• Clarify what you mean by lower respiratory tract infection. A diagnosis of lower respiratory infection needs to be further specified as to whether it is bronchitis, pneumonitis, or pneumonia. In children, it may be bronchiolitis. Ask the physician for more specific information. If no other information is available, assign code 519.8, Other diseases of respiratory system not elsewhere classified.

• Clarify whether a condition on the diagnosis list is valid now if not found in the body of the medical record. The listing of the diagnoses on the attestation statement is the attending physician’s responsibility. If there is a diagnosis listed for which no supporting documentation appears in the body of the medical record, it may be necessary to consult with the physician before assigning a code. Reporting of conditions for which there is no supporting documentation may be questioned by external reviewers.

• Clarify type 1 or type 2 diabetes. If the physician is prescribing insulin and does not indicate whether the diabetes is insulin-dependent, it would be appropriate to ask the physician to designate whether the patient is type 1 or type 2. However, it is incorrect to change the physician’s designation of non–insulin-dependent, type 2 diabetes mellitus, to insulin-dependent, type 1, without the attending physician’s concurrence.

• Clarify which of many types of angina is appropriate. Frequently, a diagnosis of angina will be documented in the medical record without further detail. The attending physician should be queried and asked to document the specific type of angina since a patient who is admitted to the hospital would usually be treated for preinfarctional or unstable angina (code 411.1, Intermediate coronary syndrome). Without further specification, the diagnosis of angina would be assigned code 413.9.

• Clarify whether evidence demonstrates in the body of the medical record that this represents acute blood loss anemia. The Official Coding Guideline 3.5 states: “Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the physician indicates their clinical significance. If the findings are outside the normal range and the physician has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the physician whether the diagnosis should be added.”

• Clarify whether the path report is clinically appropriate to this hospitalization for specificity only if path diagnosis is not validated elsewhere. Yes, it is appropriate to consider the diagnostic statement on the autopsy report to provide greater detail or specificity. Coding is based on physician documentation; the pathologist is a physician. However, if there is conflicting information in the record, or if the autopsy report includes a condition not mentioned anywhere else on the record, query the attending physician for clarification and to determine whether the diagnosis should be included in the final diagnostic statement.

— Robert Gold, MD, is CEO of DCBA, Inc., an Atlanta-based firm that provides physician-to-physician training in clinical documentation improvement along with clinical education to HIM professionals. He can be reached at DCBAInc@cs.com or 770-216-9691.

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