In order to determine what makes a query leading versus non-leading, I would like to use a coding question I received recently. It goes like this…
“Our doctors here frequently document ‘acute respiratory distress.’ They are using J80 for this, which codes to ‘acute respiratory distress syndrome’ (ARDS).”
I responded by noting that “ARDS” is a life-threatening condition whereas “acute respiratory distress and insufficiency” are symptoms that may indicate a range of conditions that vary from mild to serious. After going on to describe in detail the differences, I was sent a follow-up question about a “similar situation, except in this case, my patient has severe COPD & pseudomonas PNA and chronic respiratory acidosis.”
“He meets the criteria for chronic respiratory failure; however, the doctor never mentions any respiratory failures, distress, insufficiency, etc.,” the question continued. “Would it be appropriate to mention the clinical findings and ask if that condition (respiratory failure, chronic, acute, other, undetermined, etc.) is being treated? Or would this be considered leading or ‘introducing’ a condition since it was not mentioned in the chart?”
”Clinical truth” is a phrase everyone should keep in mind at all times in order to ensure that one’s actions are compliant and will withstand scrutiny. The clinical truth is the underlying principle behind the AHIMA/ACDIS practice guidelines on the query process. When your intentions are on the side of the clinical truth, the formulation of your queries will not be leading.
In order to grasp the concept of clinical truth, one should be knowledgeable of what defines the condition. Research the condition and understand how it differs from other conditions; e.g., what differentiates a localized infection such as pneumonia from the systemic inflammatory response of sepsis. A better understanding of the condition lets you know when to generate a query and also how to create a better query. The patient’s narrative should be consistent with the diagnosis about which you are querying.
In the coding question originally presented, parameters were met for chronic respiratory failure, but “failure, distress, or insufficiency” was not mentioned. “Chronic respiratory failure” is not something that was pulled out of a magic hat. It was present and clinically supported, but not documented appropriately. In the same vein, there were no indications that the patient was having a hard time breathing, so the query choice of “acute respiratory failure” should not have been presented. That would be introducing a new condition!
“Introducing a condition” means that a completely new entity with no clinical support is being presented; e.g., a patient has fever and leukocytosis and infiltrates in the lungs and has been diagnosed with pneumonia, so then you query for sepsis based on the presence of fever and leukocytosis.
Fever and leukocytosis may all be explained by the pneumonia! The introduction of “sepsis” is completely inappropriate in the above scenario. Are there other findings that go beyond pneumonia? Does the patient have hypotension or change in mental status or decreasing renal function that did not resolve with IV fluid replacement within 4-6 hours or cannot be explained by other factors/conditions (e.g. hypovolemia, drug effects, other comorbid conditions)? Findings such as those indicate that there may be a systemic inflammatory response component consistent with sepsis (after excluding other conditions).
Asking inappropriate queries are in fact leading; e.g., querying for sepsis based on fever and leukocytosis ultimately will change provider behavior and get them to document sepsis erroneously. Be careful in making queries, and do so only when there is clinical support for it. Let clinical truth be your guide and your efforts will be fully rewarded with a clear conscience that will let you sleep well at night.