Well, it has started happening.
As I feared, there are coders who want to link any and all hypertensive patients who also happen to have chronic heart failure (CHF) and/or renal failure all together.
“So, what is wrong with that?” You may ask.
The problem is that they are doing it even when there is strong evidence in the records that the CHF is being caused by some other problem other than hypertension. The reports I am hearing are that coders and those with coding backgrounds are discounting the opinions of the clinical documentation improvement (CDI) nurses when clinical evidence in the record suggests an alternative cause of the etiology, suggesting the need for a query.
For example: consider a patient who has CHF, hypertension, and chronic kidney disease (CKD), Stage 1, who automatically gets all the dots connected under the new rules. What if the CDI specialist sees that the patient also has aortic stenosis or a longstanding history of atrial fibrillation? Both are conditions that overwork the heart and lead to both cardiomyopathy and CHF.
What if the patient also had a history of some pretty significant coronary artery disease? To the clinically trained, this may represent some confusion about the true etiology of the CHF, as it may be ischemic. There are a myriad of reasons not related to hypertension that could explain why CHF may occur. They range from the congenital to the very slow progressive to the suddenly catastrophic.
When an alternate cause of an etiology exists in a record, the CDI specialist now should be fully aware of the guideline that could push the coding and billing into an ICD-10 code and DRG that may not accurately reflect the clinical truth of the presentation, and that specialist should view a query as fully warranted. Sure, it usually is the hypertension; you will get no argument from me there. And yes, when all things are equal and the physician just isn’t sure, they may be fine with letting it code to the default. However, if the record is confusing enough that the CDI specialist interprets it as unclear, then I encourage the assignment of a clarification query. It doesn’t really matter if the physician ultimately agrees or disagrees, as I expect it could be a 50/50 chance he or she will or won’t in some cases. What matters is that the documentation, once unclear and subject to auditor scrutiny and confusion, is now made clear and transparent.
Don’t take my word for it. As the official guidelines state, the casual relationship should be assumed even in the absence of provider documentation explicitly linking them, “unless the documentation clearly states the conditions are unrelated.” Unfortuately, “clearly” is about as vague as it gets. What is clear to me as a clinician may not be as clear to the auditor or the coder. More importantly, what is confusing for me as a clinician may be seen as low-hanging fruit for auditors looking to deny claims on the basis of clinical validation.
We haven’t heard the last of this. As I mentioned previously, if I ran an audit company right now, I would be counting my extra dollars to come. You can bet they will be attacking this coding guideline when they disagree from a clinical perspective.
The bottom line is that if your CDI specialist thinks they see alternative possible etiologies and the record appears confusing, you have a couple of options: you can allow the query, or you can be prepared to not blame your CDI team or consultant when the denials and penalties start rolling in.
They did, after all, warn you.