Clinical Documentation Improvement (CDI) Assignment
Part 3 – Your facility received an initial DRG validation denial letter from the RAC. The case scenario includes a 75-year-old patient admitted through the Emergency Department for renal failure and COPD exacerbation. The reason for admission is COPD exacerbation. The physician also documented protein-calorie deficiency malnutrition in the discharge summary. The Clinical Documentation Specialist notices that the physician’s supporting documentation is missing, including whether this condition was present of admission.
Task 1: Realizing that you will need to add Querying to your process list, clearly identify the intent of queries included in a procedure format and provide examples of why a provider might receive a query.
Task 2: It is time to address the case at hand.
The RAC suggests that the patient did not have protein-calorie deficiency malnutrition.
Identify a scholarly article on protein-calorie deficiency malnutrition (i.e. Google Scholar or other scholarly resources then write a query to the physician to address the MS DRG for principle diagnosis of COPD exacerbation with protein- calorie deficiency malnutrition.
You may add additional detail to the case such as medications, treatments, and such to support query development. *Remember, you do not want to make your query leading!
Expert Solution Preview
Introduction:
This assignment focuses on Clinical Documentation Improvement (CDI) in the medical field. The case scenario involves a denial letter from the RAC regarding the DRG validation of a 75-year-old patient admitted for renal failure and COPD exacerbation. The physician documented protein-calorie deficiency malnutrition in the discharge summary, but the documentation was missing. This assignment includes two tasks related to querying and addressing the case at hand.
Task 1:
The intent of queries included in a procedure format is to ask healthcare providers to clarify or specify documentation in the patient’s medical record. Providers may receive a query for various reasons, such as incomplete documentation, discrepancies, or conflicting information. Queries should be clear, concise, and non-leading. Examples of reasons for queries include:
1. Clarification of clinical indicators: A query may be sent if the documentation lacks specificity or does not support the diagnosis or condition documented.
2. Documentation of complications or comorbidities: A query may be sent if there is evidence of a complication or comorbidity that is not documented or coded.
3. Identification of underlying conditions: A query may be sent if there is evidence of an underlying condition that is not documented or coded.
4. Clarification of treatment or procedure: A query may be sent to ensure accurate coding and classification when the documentation is unclear or conflicting.
Task 2:
Protein-calorie deficiency malnutrition is a serious condition that can complicate patients’ health outcomes and prolong hospital stays. In this case, the RAC suggests that the patient did not have this condition, which contradicts the physician’s documentation. To address this issue, a query can be sent to the physician asking for clarification and supporting evidence for the diagnosis of protein-calorie deficiency malnutrition. The query should be objective, non-leading, and based on reliable sources of information such as scholarly articles.
Scholarly articles provide evidence-based information that supports medical diagnoses and treatments. For instance, a study published in the Journal of the American Medical Association (JAMA) found a significant correlation between malnutrition and hospital readmissions, lengths of stay, and mortality rates. The article also highlights the importance of accurate documentation of malnutrition in the medical record and the need for CDI programs to address this issue. Thus, a possible query to the physician could be:
Dear Dr. X,
The patient’s medical record indicates a diagnosis of protein-calorie deficiency malnutrition in the discharge summary. However, the RAC suggests that this condition was not present during admission. Can you please provide supporting information for this diagnosis, such as laboratory results or clinical assessments? Also, can you clarify whether this condition was present on admission or developed during the hospitalization? Your prompt response is appreciated.
Sincerely,
CDI Specialist Y.
