Dr. Ronald Hirsch inspired this article – months ago, he asked me to look at a publication from Livanta and comment on it.
Livanta is a Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO), and one of its jobs is medical case review, to ensure that Medicare patients in their jurisdiction are receiving medically appropriate care and services. Their monthly publication, The Livanta Claims Review, from last August focused on the condition of cerebral edema (The Livanta Claims Review Advisor, Volume 1, Issue 19).
In it, they quote the Recovery Audit Contractor (RAC) Statement of Work in that “clinical validation involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented in the medical record.” Livanta asserts that “clinical validity reviews are performed by currently practicing physician reviewers. The most common reason for denial of cerebral edema on claims is a failure of the provider to document the clinical information that supports the diagnosis – there is often no documentation of cerebral edema at all until the post-discharge query. It is vital for providers to document the clinical information that led to the diagnosis of cerebral edema rather than simply stating on a query that it is present.”
We must keep in mind that reviewers are making their judgments solely based on the available documentation.
It is completely legitimate to expect documentation to demonstrate that a condition being claimed and coded is clinically valid. The Livanta publication also has a section on Good Documentation Practices. Their expectation is that there will be documentation of the following:
- Clinical signs or symptoms such as headache, vomiting, altered mental status, or seizures;
- Findings on imaging. They only mention MRI, but CT scans may also reflect changes consistent with cerebral edema. They offer phraseology such as “brain compression,” “displacement,” or “midline shift.” I will add “mass effect” to their list. Later on in the document, they note that “vasogenic edema” isn’t found in the coding index, specifying that the words “cerebral” or “brain” must be linked with “edema;” and
- Clinical significance supported by documentation of treatment. Corticosteroids, mannitol, surgical decompression, a plan to monitor with repeat imaging, or a documented linkage between the condition (cerebral edema) and clinical deterioration could serve as evidence that the condition is not just an incidental and inconsequential radiological finding.
Post-discharge queries that result in a diagnosis of cerebral edema after the fact, without evidence of clinical significance, are to be dismissed, according to Livanta’s instructions.
This condition is illustrative of the concept that clinical validity is often predicated on clinical significance. A condition may be diagnosable, but not relevant if it does not impact the current encounter. A diagnosis is not codable if it is not documented in an appropriate format.
Some of you may have seen my macro for sepsis before: sepsis due to (infection) with acute sepsis-related organ dysfunction as evidenced by (specify organ dysfunction/s). This guides the provider to give the etiology and the evidence of clinical significance.
For all conditions, providers should be instructed to document their clinical support (signs and symptoms), any laboratory or imaging evidence bolstering the diagnosis, and what is being done about it (or when treatment is considered, but declined by the patient).
A single reference to a condition is only weak evidence; it is preferable for the discussion and diagnosis to appear multiple times in the record. It needn’t be redundant copying and pasting. Each day the provider should ponder and document how the situation is progressing. Are the symptoms improved? Are there new or worsening clinical indicators? Is the treatment succeeding, or does it need adjustment? A single mention in a post-discharge query very well may not be adequate support of a codable diagnosis, because if it was clinically significant, wouldn’t it have been noted and treated prior to discharge?
For this targeted condition, consider this model documentation:
Cerebral edema due to known glioblastoma, as evidenced by severe headache and projectile vomiting, new since Friday. MRI confirms increased brain compression and cerebral edema. Will administer dexamethasone and consult neurosurgery to assess for urgent decompression.
Determination of clinical significance shouldn’t be left to the imagination or whim of the reviewer. The provider should think in ink and explain why they are making their diagnoses (and what they are doing about them). Clinical documentation improvement specialists (CDISs) should do their traditional querying early to get the diagnosis input promptly. If there is inadequate support in the documentation, a clinical validation query may be indicated to ensure that the diagnosis is removed if not valid (or documentation is improved if it is valid).
Training the provider to supply linkage and evidence of clinical significance is a good proactive step. And it is a best practice for the diagnosis to appear when first noted, as it is treated, and as it resolves, and then brought back into the spotlight in the discharge summary.
