Physician engagement in CDI continues to be an obstacle for many organizations, including those that have strong clinical leadership. It is important to take a step back every now and then to listen carefully or observe what frustrates some physicians with the CDI process.
I have included some of the common “gripes” I have heard from physicians over the years. I have chosen, specifically, not to include common “myths” believed by physicians surrounding CDI, a topic that I will address in a subsequent post.
Not Taking The Full Clinical Picture Into Account
Physicians are often frustrated by queries that, in their minds, are querying for information that does not take the full clinical picture into account. This is always a challenge for the clinical documentation specialist, as they are not the ones examining or treating the patient.
I will point out that queries are, for the most part, generated based on information or clinical indicators already provided in chart, so if a physician wants to avoid a query, then their thought process must be explicitly documented. There will always be instances where a query is generated and the physician feels like the clinical picture is not considered.
My advice to physicians would be to always document their clinical thought process, and for documentation specialists to be cautious of submitting “knee-jerk” queries. These are queries that are submitted based on a historical trend or a patient meeting certain criteria, but the full clinical picture is not considered. For example: Patients who have pulmonary edema and get IV Lasix don’t always have acute heart failure.
Receiving A Query Too Early
Sometimes, a physician may receive a query even before they have enough evidence to support a diagnosis. They may be awaiting further lab tests or imaging study results before they can confidently consider a specific diagnosis to be clinically significant for that case.
Once again, instances will occur where a CDS will have to query on a diagnosis based on information in the chart, but always consider that a physician may be awaiting further testing and/or results before deciding about a diagnosis. In some cases, there may be motivation to query on a diagnosis that impacts the DRG assignment, but if the physician would have documented the condition(s) the next day anyway, then querying only complicates the process and could frustrate the physician.
Unclear Diagnostic Or Clinical Criteria
This is the result when clear diagnosis definitions and criteria are not well communicated to physicians at the bedside, as well as when queries are not consistent in referencing these criteria. Standardization of definitions, not only amongst physicians, but CDSs and coders, will be crucial to ensure consistency for the queries generated.
In other instances, clinical validity will be necessary when a patient clearly does not meet the approved definitions or criteria. Educating physicians on the importance of complete and accurate documentation will be necessary to ensure that if they still consider a diagnosis to be pertinent even though it does not meet the clinical criteria, then they need to explicitly document their medical decision-making to support their clinical decision. Documenting such a condition and then answering a clarifying query with, “Because I said so.” won’t suffice for your program, and definitely won’t suffice during an audit or as part of an appeal.
Queries For Clinically Insignificant Diagnoses
This is another instance where physician education plays a big role. It will be necessary to educate physicians on what is considered clinically significant in the documentation and coding world versus what they have been taught.
I believe that once a physician fully understands what should be documented as secondary diagnoses based on the Uniform Hospital Discharge Data Set (UHDDS), then the door will be left open for many diagnoses that have been previously thought of to be clinically insignificant in the physician’s mind. For example: The documentation of diagnoses such as hyponatremia and paralytic ileus come to mind.
Frequently, physicians are also confused by queries and are not sure what is being asked. Hence, we often hear them say: “Just tell me what you want me to document!”. If only it were that easy, but physician education can go a long way in these cases.
While many of these scenarios cannot be avoided, it is important to be aware of them and, if possible, make an earnest attempt to avoid them. There is significant competition for a physician’s time in healthcare, and when we claim that the CDI profession is there to help a physician, we better ensure that we do everything in our power to live up to that claim.
“Complaints often contain the seeds for growth.” - Skip Prichard