What is leading and what isn’t?
Is asking for clarification leading?

In 2000, a note was released by CMS that forbade individuals from asking physicians questions in order to assign codes from their answers. It was followed by a subsequent note which stated that it was acceptable to ask physicians questions and to assign codes from their answers. Health information management professionals have been in a quandary as to how to ask questions ever since.

Eventually, a Code of Ethics was published which included a statement that said it is inappropriate to ask a “leading” question. And just as in the previous sentence, the word “leading” was in quotation marks. However, they didn’t define “leading.” They left it up to the interpreter to define “leading.”

Many of us in the consulting and health information management professions have read the guidelines from cover to cover, have read Coding Clinic from cover to cover, have discussed with the gurus, and have come to the conclusion that there is a true definition as well as true guidelines based on that definition. Now, AHIMA is returning to the drawing board to better define the ethics involved in asking questions of physicians.

To summarize our independent conclusions, it is inappropriate to ask a physician to provide documentation regarding a condition that has no supportive basis in the medical record.  Asking a physician to provide documentation of a symptom or of an x-ray finding as a “condition” when the diagnosis is clear in the medical record is also unacceptable. Lastly, it is inappropriate to ask a physician to document a condition:

• In which he has absolutely no interest based on labs or x-ray findings
• Which is untreated and totally irrelevant to the care of the patient just to get a CC or MCC code assigned
• Where the lack of attention to or lack of treatment of would not lead to meeting Uniform Hospital Discharge Data Set criteria for a valid secondary diagnosis
• Just for the financial benefits of the bill

If a physician uses terminology that leads to incorrect code assignment, it is appropriate to guide that physician to the words that would lead to a code for the condition that:

• The patient absolutely has
• Is treated
• Is a major part of the patient’s total care  

Use of incorrect terminology can happen because the doctor doesn’t know the verbiage that is appropriate to the case and to the care of the patient. And of course, it is also totally appropriate to help a physician document a condition that is fully supported in the body of the medical record.

Some of these statements are certainly bold—and I’m sure that some of these sweeping statements are also mystifying—so I’ll provide you with a few examples.

1. A patient arrives to the emergency department (ED) vomiting massive amounts of blood that is found to be due to esophageal varices. Coming through the door, the hemoglobin is 14 and resuscitation with Ringer’s Lactate or half normal saline is performed. When packed cells are cross matched and available, an emergency esophagastroscopy is performed with ligation of the varices. The patient stabilizes and the hemoglobin, after all is said and done, has dropped to 7.2. The physician has three units of packed cells administered and the hemoglobin settles in at 9.4. The physician only calls the patient’s condition “anemia.” In this scenario, it is appropriate to ask the physician if he feels that the anemia is related to the acute blood loss from the bleeding varices or if he feels it is from another source. The evidence is there. The patient has the condition described by ICD-9-CM code 285.1 and it would be inappropriate to assign 285.9 in such a case. To not direct the physician, to not ask for the documentation that would lead to the code that describes what is truly wrong with the patient would be unacceptable.

2. A patient has an echocardiogram done for evaluation of a murmur, or for heart failure, or for an acute myocardial infarction admission. The echocardiogram shows that the left ventricle is dilated and that the ejection fraction is 20%. The physician documents “cardiomyopathy” and “EF = 20%.” It is inappropriate not to seek clarification if the findings meet the physician’s criteria for chronic left ventricular systolic failure as a background condition, along with whatever else the patient has on top of that.  Why?  It takes time for a left ventricle to dilate, thus it’s chronic. A left ventricular ejection fraction under 40% is defined by the American Heart Association and the American College of Cardiology as systolic heart failure. The patient has chronic left ventricular systolic failure at least!  Code 428.22 should be assigned. But, physicians frequently call dilated hearts “cardiomyopathy.” Why? They just do. Veterinarians onlyrecognize dilated hearts as “cardiomyopathy.” It is almost criminal not to direct the physician’s documentation with a request to provide the verbiage “chronic systolic failure” or its equivalent. You must ask for clarification of the condition that caused the cardiomyopathy—was it ischemic, alcoholic, valvular, toxic, etc. (if he knows).  Otherwise the only code to be assigned is 425.4 and that’s unacceptable. If the patient had acute heart failure, with shortness of breath and elevated brain natriuretic peptide levels, then it would be necessary to address if it was acute right heart failure or acute left heart failure. If it was left heart failure, was it due to acute systolic dysfunction, acute diastolic dysfunction, or both? Because these are the only choices.

3. An elderly patient with a history of chronic obstructive pulmonary disease and heart failure is admitted from a nursing home with pneumonia. The patient is treated with Rocephin and Zithromax which seems to be the routine at many hospitals for almost every patient with pneumonia, regardless of age or other risk factors. It would be inappropriate to ask the physician to document something like “aspiration pneumonia” or “gram negative pneumonia,” Why?  Because the treatment is not the treatment for aspiration pneumonia and it is not the treatment for gram negative pneumonia. Everyone who comes through the door gets treated with this exact same regimen and they don’t all have gram negative pneumonia or aspiration pneumonia. On the other hand, when the patient fails to respond to the original regimen, and the cultures demonstrate a specific organism growing on culture, and the antibiotics are altered to cover that specific organism, then it is very appropriate to ask for clarification if the pneumonia is caused by the organism. If the workup demonstrates aspiration events while in the hospital and the antibiotic regimen is changed to one that is appropriate for treatment of aspiration pneumonia, then it would be irresponsible not to ask if the physician felt it was aspiration pneumonia.

4. A patient arrives with shortness of breath and an x-ray shows pulmonary edema. The patient had had atrial fibrillation with rapid ventricular response. Medical management of the tachyarrhythmia was successful in controlling the rate, the patient responded with easier breathing, and the x-ray cleared. It is inappropriate to ask the physician to document pulmonary edema or pulmonary venous congestion so that ICD-9-CM code 514 could be assigned. That’s an x-ray finding, nothing else. When coders use the x-ray finding as a substitute for the condition that the patient has in order to bump the relative weight of the DRG assignment, that’s more than inappropriate—it’s immoral. If there is any suggestion that the patient had acute diastolic heart failure due to the tachyarrhythmia and acute pulmonary edema due to a cardiac condition, one wouldn’t reach under the table so much. It just should not be done.

5. A patient comes in after three days of severe nausea, vomiting, and diarrhea from what is determined to be viral gastroenteritis. The patient also has “altered mental status,” mucus membranes are dry, and creatinine is determined to be 5.8. After two days of “rehydrating,” the creatinine drops to 1.1 and the only things documented are viral gastroenteritis, nausea, vomiting, diarrhea, and the creatinine values. There is nothing wrong with asking the physician—based on guidelines established as valid by the National Kidney Foundation and described in Coding Clinic in the references of acute renal failure—if this case meets the physician’s criteria for acute renal failure due to dehydration or something else. This is possible because the patient has acute renal failure but the words the physician used would not lead to the codes that describe what’s wrong with the patient. Consequently the data would be flawed and it is not right to leave it as it is documented. How can you possibly ask an “open ended” question in such a circumstance? You have to lead the physician to words that would demand the correct code assignments.

Does this always apply? No, not really. Sometimes you just don’t know. And that’s alright—you have to ask an open-ended question. If there’s no evidence regarding the cause of a stroke with which the patient was transferred to your facility, you might ask the physician, if the stroke is hemorrhagic or ischemic. And, if it is ischemic, is it embolic or locally occlusive. Why can you ask this?  Because they’re the only choices and the patient has to have one of them. But if the physician hasn’t provided any reason for a patient’s syncope, you might ask an open ended question like, “Have you determined a cause of the syncope?”  And, you know what?  Sometimes physicians just never know.