The Importance of Clinical Validation Queries: Part III

I recently mentioned that some facilities are receiving payer denials through which a reportable, clinically valid, documented diagnosis is removed from a claim because the payer deems the query invalid or non-compliant.

One of the most cited reasons for a query denial is “not all reasonable options were included.” Since I addressed common query myths related to multiple-choice query choices last week, I thought it might be helpful to take a deeper dive into how to select reasonable query response options.  

Many of the reasons cited by payer query denials are contrary to the American Health Information Management Association (AHIMA) and Association of Clinical Documentation Integrity Specialists (ACDIS) Guidelines for Achieving a Compliant Query Practice Brief (2022 Update). Remember, AHIMA has the authority to set industry guidance as a cooperating party for ICD-10-CM, and adherence to ICD-10-CM is required under the Health Insurance Portability and Accountability Act (HIPPA).

The Query Practice Brief even states that it was developed to “establish and support industry-wide best practices for clinical documentation query processes (documentation clarification) . . . to provide a resource for all stakeholders including external reviewers.” Additionally, “the guidance is to be used by payers, auditors and compliance agencies in health record reviews impacting Diagnosis Related Group re-assignment, claim denials, post-payment findings, risk adjustment, medical necessity of care, and code assignment.” Those fulfilling the role of CDI, coding, or physician advisement, regardless of if they work for a PAYER or hospital, are all required to adhere to these guidelines.

I approach determining which query choices to include like I would a clinical validation review. Let’s say the health record includes a history of heart failure (HF). Is a query necessary or not? ICD-10-CM Official Guidelines for Coding and Reporting states,

“While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter . . . Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient’s condition at the time of that particular encounter.”  

Some CDI and coding professionals have been trained to always query for additional specificity when heart failure is documented. The reality is that a query is only necessary if there is clinical evidence suggestive of a more specific diagnosis. It is perfectly acceptable to report an unspecified code, like I50.9 Heart Failure, Unspecified, when it accurately reflects the clinical scenario.

The Query Practice Brief also instructs us “not to query if the provider cannot offer clarification based on the present health record,” but we can “clarify documentation using evidence from a previous encounter. . . when relevant to the current encounter.” Often, the CDI professional will search the current health record and previous encounters to find a recent echocardiogram with documentation of the patient’s left ventricular ejection fraction (LVEF). Let’s say the patient has a recent ejection fraction (EF) of 36 percent. Based on this information, it would be appropriate to query the provider for additional specificity.

Now that we know we are going to query the provider for greater specificity, which is an acceptable reason to query, “to avoid reporting a default or unspecified query,” we need to determine reasonable choices to include as options. The Query Practice Brief specifically instructs us to “only offer multiple choice answer options that are clinically credible. Remove imbedded answers options {from query templates} that are not clinically credible or relevant.” ICD-10-CM has many different codes for heart failure. The query professional needs to clinically validate each possible option to make sure it is a credible option based on the available clinical indicators (i.e., an LVEF of 36 percent).

Unlike some conditions in which there is a lot of variability in how it is diagnosed, there is a medically credible resource for heart failure with terminology that aligns with ICD-10-CM coding language. The Universal Definition and Classification of Heart Failure (2021) differentiates the types of heart failure as follows:

• HF with LVEF ≤ 40% = HF with reduced EF (HFrEF);
• HF with LVEF 41-49% = HF with mildly reduced EF (HFmrEF);
• HF with LVEF ≥ 50% = HF with preserved EF (HFpEF); and
• HF with left ventricular ejection fraction (LVEF) ≤ 40% = HF with reduced EF (HFrEF).

When considering the available clinical evidence of an LVEF of 36 percent and documentation of HF, neither diastolic or combined systolic and diastolic HF are reasonable options, and they should be removed from the query template.

In fact, it should be rare for both systolic and diastolic HF to be on the same query, because if a patient has both systolic and diastolic HF, the best diagnosis code would be combined HF. How do you know if combined HF should be included as a choice? If a patient has clinical indicators of systolic HF (i.e., a LVEF ≤ 40) and documentation of diastolic dysfunction, the alphabetic index maps to combined HF, so it would be a reasonable choice. It would be difficult for a provider to diagnose combined systolic and diastolic heart failure on the LVEF alone.

Are there other options that are clinically relevant, and therefore, should be included? Not really; left-sided HF is less specific than systolic HF, because both systolic and diastolic HF are types of left ventricular HF, which is why the LVEF is used to differentiate between the two.

It could be possible that the patient has clinical indicators of right heart failure with excess fluid in the extremities, so it might be reasonable to query for biventricular heart failure, but that would be a separate query. There is a code-also note at I50.82 (biventricular query) allowing both biventricular HF and the type of left ventricular failure to be coded (e.g., systolic, in this example). It is not an either-or choice between biventricular HF or systolic HF; hence, an additional query would be necessary.

Compliant multiple-choice query construction requires the ability to critically think about the clinical evidence to determine reasonable query choices.

When using query templates, be sure to remove choices that are not supported by the clinical evidence within the health record.

Additionally, if a query is challenged by a payer because it did not include “all reasonable options,” reference the Query Practice Brief and credible clinical resources, if available, within your appeal.

Programming note:

Listen every Tuesday when Cheryl Ericson reports the latest CDI news and information on Talk Ten Tuesday with Chuck Buck and Angela Comfort, 10 Eastern.