ACDIS/AHIMA Practice Brief: A Gold Mine for Best Practices

Providers would benefit from heeding the advice of the newly updated file.

The Association of Clinical Documentation Integrity Specialists (ACDIS) and the American Health Information Management Association (AHIMA) joint Practice Brief, Guidelines for Achieving a Compliant Query Practice (2022 Update), was released on Monday, Oct. 10. Last week, I asserted that it is our industry’s new best-practice standard. This week, I would like to explore a few interesting details.

On page 4, the Practice Brief notes that a query may be necessary “to clarify a diagnosis on an ancillary note that has been signed by a provider.” For example, if a nutrition note cites “severe malnutrition” and the note is signed by the provider, but the provider does not address the diagnosis within their documentation, a query may be needed. This is indicating that a signature on someone else’s note may not be sufficient.

Malnutrition exemplifies this. The dietitian performs their assessment, and the organization channels it over to the provider for a signature. If the provider doesn’t perform an attestation and/or bring the diagnosis into their documentation, this could generate a query. A best practice is for the provider to list the diagnosis, how they came to that conclusion, and the plans for treatment of the condition in the progress note. The goal isn’t just to get credit for making the diagnosis, it is to render excellent clinical care to a malnourished patient.

Other sections note that queries and templates should not include titles that could be construed as leading or identifying a desired diagnosis that is not already documented. These titles should not include impactful information such as reimbursement or quality implications. For instance, if a patient has an infection and organ dysfunction, but no mention of sepsis has been made in the record, a query entitled “sepsis” would be inappropriate.

Dr. James Kennedy brought to my attention a change. The previous version of the Practice Brief warned against using uncertain diagnosis words in query response choices unless the query was at or post-discharge. The newest iteration recommends avoidance of terms of uncertainty unless the provider has already used one themselves. I think a best practice is to educate your providers into knowing that uncertainty is an option, and let them insert their uncertainty in their documentation.

Does your electronic medical record notate CC, MCC, or HCC next to diagnoses? The Practice Brief states that even in a problem list, elements that reflect financial reimbursement or quality impact should not be identifiable. I think this is also pertinent because I have seen final diagnoses also have those components included. CC/MCC/HCC/PSIs/mortality variables are fine for education, but have no place in documentation or diagnosis lists.

This Practice Brief also says with its outside voice that physician advisors should not be queried. Only providers who are delivering direct care to a patient during an encounter may be queried. This is different from the utilization management realm, where physician advisors are integral to the process.

A compliant query that has been asked, answered, and is part of the permanent health record can be coded. The response is not mandated to be repeated in the health record. It also notes that queries must either be part of the medicolegal health record or be retrievable in the business record. My personal leaning is towards “no” on this.

My reasoning:

• Queries are always discoverable. If you are confident that your clinical documentation improvement specialists (CDISs) invariably perform compliant queries, then including them in the medicolegal record may be satisfactory. However, if you would like to make the payors or government work to find noncompliance, then do not include them in the official permanent record.
  
• However, queries are handled, as a best practice, especially concurrently, by incorporating diagnoses arrived on through query into the subsequent documentation. It is always preferable to see a diagnosis more than once in a record, and as more than just as a response to a query, to support inclusion as a secondary diagnosis.

The Practice Brief is adamant that even queries generated by technology must be compliant. CDISs who use computer-assisted technology must distinguish between legitimate query opportunities and inappropriate triggers, and real-time, computer-assisted physician documentation and autogenerated artificial intelligence queries are bound by the same rules for complaint query design as the human being-generated ones.

Such a well-done thesis! Great job, ACDIS and AHIMA! Thanks for such clear and reasonable guidance.

Programming note: Listen to Dr. Erica Remer on Talk Ten Tuesdays every Tuesday at 10 Eastern when you cohosts with Chuck Buck