Knowledge Base Article

Let me start off by saying, there is no denying the importance and need of a physician advisor, especially in this day and time of Medicare compliance audits. Years ago the hiring of a physician advisor seemed more or less optional but as time moves forward the physician advisor’s role has become an integral component within the Clinical Documentation Improvement (CDI) program.

Physician advisors are a great asset to a hospital and they serve as a much needed bridge and advocate between the provider (attending physician) and CDI, coders and HIM. They play a very important role as an inside consultant working as an influential diplomat in accomplishing goals by using their clinical knowledge, their understanding of quality standards & metrics and the importance of coded data to a hospitals present and future reimbursement.

With all this being noted, there are also limits to a physician advisor’s responsibilities. As a licensed physician, they cannot change or add additional documentation in a patient’s record in which they themselves have not provided direct medical care. They also cannot use their own opinion to override a diagnosis provided by the provider. If the physician advisor’s opinion differs from that of the provider, then he/she must contact that particular physician and follow the industry standard guideline for communication (e.g., speaking one on one or querying).

At the end of the day when all is said and done; the provider that has clinically evaluated the patient, developed a therapeutic treatment plan and/or procedure(s) and established a diagnosis is the one responsible for that diagnosis both legally and morally. A provider could possibly deny responsibility should anyone, physician advisor included, override their professionally established diagnosis. Can you imagine the legal ramifications that could bring on the hospital/facility?

There will definitely be times when a physician advisor, CDI and/or coder may feel that clinical indications currently listed in the record need to be specified further in order to give greater support. Of course in these situations a query should be sent. The 2008 AHIMA practice brief titled, “Managing an Effective Query Process” noted the following guideline:

“Codes assigned to clinical data should be clearly and consistently supported by provider documentation. Providers often make clinical diagnoses that may not appear to be consistent with test results. For example, the provider may make a clinical determination that the patient has pneumonia when the results of the chest x-ray may be negative. Queries should not be used to question a provider’s clinical judgement, but rather to clarify documentation when it fails to meet any of the five criteria listed above – legibility, completeness, clarity, consistency, or precision… In situations where the provider’s documented diagnosis does not appear to be supported by clinical findings, a healthcare entity’s policies can provide guidance on a process for addressing the issue without querying the attending physician.”

There are no guidelines which allow an override process when it comes to the attending provider and a patient’s diagnosis. Per Section I.A.19 of the ICD-10-CM Official Guidelines for Coding and Reporting, “The assignment of a diagnosis code is based on the provider's diagnostic statement that the condition exists.  The provider's statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

Greater detail on the reporting of a diagnosis code is found in Coding Clinic 4th Qtr. 2016 page 147. “Coding must be based on provider documentation. This guideline is not a new concept, although it had not been explicitly included in the official coding guidelines until now. Coding Clinic and the official coding guidelines have always stated that code assignment should be based on provider documentation. As has been repeatedly stated in Coding Clinic over the years, diagnosing a patient's condition is solely the responsibility of the provider. Only the physician, or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis, can "diagnose" the patient. As also stated in Coding Clinic in the past, clinical information published in Coding Clinic does not constitute clinical criteria for establishing a diagnosis, substitute for the provider's clinical judgment, or eliminate the need for provider documentation regarding the clinical significance of a patient's medical condition.”

The physician advisor should help to monitor a provider that may have developed a trend of establishing a diagnosis that consistently results in denials and/or penalties and puts the facility at risk for lost reimbursement. In cases such as this, the established steps should be taken to rectify the situation. It is clearly not the role of the physician advisor to establish that final diagnosis of a patient’s condition.

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful

References:

Clinical Criteria and code Assignment - Coding Clinic 4th Quarter 2016 Page 147 – Oct. 1, 2016

Section I.A.19 of the ICD-10-CM Official Guidelines for Coding and Reporting – October 1, 2016

The Physician Advisor’s Guide to Clinical Documentation Improvement - 2014
https://store.healthleadersmedia.com/aitdownloadablefiles/download/aitfile/aitfile_id/1720.pdf

ICD-10 Monitor: Controversial – Attending Physicians Denying Responsibility? – Nov. 28, 2016
https://www.icd10monitor.com/controversial-attending-physicians-denying-responsibility

Defining the Role of a Physician Advisor - August 15, 2007
http://www.hcpro.com/REV-75168-5354/Defining-the-role-of-a-physician-advisor.html

Who Makes a Good Physician Advisor and What Can They Do For You? – May 6, 2016
https://www.ahcmedia.com/articles/137835-who-makes-a-good-physician-advisor-and-what-can-they-do-for-you

The Value of a Physician Advisor – December 1, 2014
http://www.providentedge.com/the-value-of-a-physician-advisor/        

Taking Coding to the Next Level through Clinical Validation
http://library.ahima.org/doc?oid=300246#.WM_f-2Y2yUk

2013 ACDIS/AHIMA guidance titled “Guidelines for Achieving a Compliant Query Practice” – April 2013
http://www.hcpro.com/content/290814.pdf

Ask ACDIS: Escalation Policies and Clinical Validation Queries - September 1, 2015
http://www.hcpro.com/HOM-320974-5728/Ask-ACDIS-Escalation-policies-and-clinical-validation-queries.html