1. READY for Clinical Documentation Improvement/CDI?
Prepared and Presented by:
Anderson Health Information Systems, Inc.
Staci LePage, RHIT, RAC-CT, QCP

2. Objectives
Identify focused changes of Patient Driven Patient Model ‘driven’ by patient acuity, diagnosis and supporting documentation
Identify how physicians/NPs/PAs/Clinical Nurse Specialists (CNS) can assist the facility by providing complete documentation to support care and services
Learn how to complete compliant queries
Review of reasons for doing queries

3. ICD-10 Coding of Diagnoses for PDPM
ICD-10 codes now drive the reimbursement rate
Not just supporting the reimbursement
There WILL be Medicare coding edits, based on:
Correct coding practice
Supporting MD documentation
Physician’s Billing
You can look for more correlation of billing/documentation/diagnoses in different health care sites with ‘increased interoperability’

4. Definition
Clinical documentation improvement (CDI) is the process of enhancing medical data collection to maximize claims reimbursement revenue and improve care quality

5. Purpose
Clinical documentation improvement (CDI) helps ensure that the events of the patient encounter are captured accurately and the health record properly reflects the services that were provided.

6. Used For:
Successful clinical documentation improvement (CDI) programs facilitate an accurate representation of a resident’s clinical status that translates into coded data.
Coded data is then translated into
Quality reporting;
Physician report cards;
Reimbursement;
Public health data; and
Disease tracking and trending.
Documentation must be accurate, timely, and reflect the scope of services being provided.
From AHIMA

7. Members of the CDI Team The two backgrounds seen most often are:
Health information management (HIM) should be familiar with compliant documentation rules and regulations.
Nurses have a strong clinical background which helps them identify gaps in the clinical evidence and documentation.
Both of these backgrounds provide a good foundation for a CDI Program.
In your facility it could vary on who is the most knowledgeable with coding guidelines.
Regardless, knowledge of the coding guidelines and identifying missing physician documentation are key for coding under PDPM.

8. Physician Communication
Start by meeting with your Medical Director.
Pass the information to your other physicians.
Talk to them about PDPM and the need to have them clarify diagnoses (same as they do for hospitals).

9. Physicians/NP/PA/Clinical Nurse Specialist
Complete and specific diagnoses documented by the physician is needed to
Support care and billing in the SNF, and
Justifies the need for skilled care
Review the acute hospital documentation, facility History/Physical and MD progress notes
Any of these professionals can document diagnoses

10. Definition of Active Diagnosis
Definition per RAI Manual:
Physician-documented diagnoses in the last 60 days
That have a direct relationship to the resident’s current functional status during the MDS 7-day look-back period
cognitive status,
mood or behavior,
medical treatments,
nursing monitoring, or risk of death.

11. Definition of Active Diagnosis-2
Once a diagnosis is identified, it must be determined if the diagnosis is active
Cannot not include conditions that have been resolved, do not affect the resident’s current status, or do not drive the resident’s plan of care during the MDS 7-day look-back period, as these would be considered inactive diagnoses

12. Supporting Documentation for Diagnosis
Clinical Documentation Improvement process (CDI) - same as in the Acute Hospital in SNF = MD Query
Clinical documentation for the diagnoses to support accurate ICD-10 Coding for CARE & BILLING
All Medications, treatments, labs etc. must have a corresponding diagnosis and supporting documentation for care, treatment and billing
Clarify conflicting or lacking documentation - need more specificity
Make sure your office is billing diagnoses match the resident SNF chart

13. Diagnosis Identification Process
Upon admission: IDT/CDI Team should “review the medical record together the day after admission to determine the primary and other skilled diagnoses
According to the FY 2019 SNF PPS Final Rule, under PDPM, facility staff needs to determine the primary diagnosis, which is the primary reason for the Part A Medicare stay in the SNF
Therapists and Licensed Nurses/LN need to know the primary and supportive diagnoses immediately following admission
The primary diagnosis code will have to be entered on all Medicare A - 5-day and IPA MDS’.
The primary diagnosis will quali

14. CMS Program Manuals Revised (for Jimmo Settlement)
Portions of the relevant program manuals revised
No “Improvement Standard” is to be applied in determining Medicare coverage for maintenance claims in which skilled care is required
Medicare recognized that even though no improvement is expected, skilled nursing and/or therapy services to prevent or slow a decline in condition are necessary because of the particular patient’s special medical complications or the complexity of the needed services.
Coverage depends not on the beneficiary’s restoration potential, but on whether skilled care is required, along with the underlying reasonableness and necessity of the services themselves.
JIMMO VS Sebelius agreement approved by the court 1/24/2013

15. CMS Program Manuals Revised
Appropriateness of Documentation
Does not require the presence of any particular phraseology or verbal formulation as a prerequisite for coverage
Does identify certain vague phrases like “patient tolerated treatment well,” “continue with POC,” and “patient remains stable” as being insufficiently explanatory to establish coverage
Manual Provides enhanced guidance on documentation
Intended to assist providers to identify and include clinical information that effectively serves to support a finding that skilled care is needed and received
Ensure more accurate and appropriate claims adjudication.

16. Medicare Claims Manual Revisions for PDPM 11/5/19
Chapter 4 - Physician Certification and Recertification of Services
Certification for Extended Care Services
(Rev. 126, Issued: , Effective: , Implementation: )
Certifications must be obtained at the time of admission, or as soon thereafter as is reasonable and practicable (see Pub , Medicare Claims Processing Manual, Chapter 6, §120.2, regarding the circumstances under which a resumption of SNF care following a temporary break in SNF coverage would be considered a new “admission” under the SNF PPS’s Interrupted Stay policy). The routine admission procedure followed by a physician would not be sufficient certification of the necessity for posthospital extended care services for purposes of the program.

17. Chapter 3 - Duration of Covered Inpatient Services
Three-Day Prior Hospitalization - Foreign Hospital
(Rev.261, Issued: , Effective: , Implementation: )
Regardless of whether a foreign hospital stay is itself coverable under the heading of “foreign hospital services” (see Pub , Medicare Claims Processing Manual, chapter 32, §§350ff. for a description of the foreign hospital services that are payable by Medicare), an inpatient stay of 3 or more days in a hospital outside the United States may nevertheless satisfy the prior inpatient stay requirement for post-hospital extended care services within the United States as long as the foreign hospital can qualify as an “emergency hospital” (see Pub , Medicare General Information, Eligibility, and Entitlement Manual, chapter 5, §20.2, for the definition of an emergency services hospital).

18. Chapter 3 - Duration of Covered Inpatient Services
30.1 – Administrative Level of Care Presumption
(Rev.261, Issued: , Effective: , Implementation: )
Under the SNF PPS, beneficiaries who are admitted (or readmitted) directly to a SNF after a qualifying hospital stay are considered to meet the level of care requirements of 42 CFR up to and including the assessment reference date (ARD) for the initial Medicare assessment prescribed in 42 CFR (b), when correctly assigned one of the case-mix classifiers that CMS designates for this purpose as representing the required level of care. While this assessment is commonly referred to as the “5-day” assessment (reflecting its original 5-day assessment window), an additional 3 grace days have always been available beyond that window for actually setting the ARD; further, as of October 1, 2019, those additional 3 grace days are directly incorporated into the assessment window itself, thus resulting in an overall 8-day assessment window.

19. Chapter 3 30.1 – Administrative Level of Care Presumption
For purposes of this presumption, the assessment reference date is defined in accordance with 42 CFR (d), and must be set for no later than the eighth day of posthospital SNF care. Consequently, if the ARD for the initial Medicare assessment prescribed in 42 CFR (b) is set for day 9, or later, the administrative level of care presumption does not apply. The coverage that arises from this presumption remains in effect only for as long thereafter as it continues to be supported by the facts of the beneficiary’s condition and care needs. Accordingly, the SNF is expected to monitor carefully for and document any changes in the patient’s condition, in order to determine the continuing need for Part A SNF benefits after the ARD. Moreover, this administrative presumption does not apply to any subsequent assessments.

20. Chapter 3 30.1 – Administrative Level of Care Presumption
If a beneficiary who has been in a covered Part A stay requires readmission to a hospital, and subsequently returns directly to the SNF for continuing care, a new initial Medicare assessment under the regulations at 42 CFR (b) would be required if the beneficiary’s absence from the SNF exceeds the 3-day interruption window specified under the SNF PPS’s interrupted stay policy (see Pub , Medicare Claims Processing Manual, Chapter 6, §120.2). In this scenario, there is a presumption that he or she meets the level of care criteria upon direct readmission from the hospital to the SNF when correctly assigned one of the case-mix classifiers that CMS designates for this purpose as representing the required level of care. The resulting presumption of coverage lasts through the assessment reference date (ARD) of that assessment, which must be set for no later than the eighth day of the stay. Alternatively, if the absence from the SNF does not exceed the 3-day interruption window, the beneficiary’s return to the same SNF would represent a continuation of the previous SNF stay; as such, there would be no new initial Medicare assessment and no new presumption of coverage; however, any days remaining from the previous presumption would continue to apply through the ARD of the original assessment.

21. Specificity of Diagnoses
This is VERY important for PDPM!
If specificity is NOT documented by the provider or there is conflicting/unclear documentation, MUST query the MD to obtain needed information from the provider.
Whoever is coding diagnoses MUST verify codes for complete/accurate codes.
Have Medical Records update information in computer system when diagnosis is clarified, print updated diagnosis list.
If you are not clear of a diagnosis – for example traumatic vs pathologic fx, it is not going to be clear to a reviewer either!
Most facilities still need to implement this process!
Common issues that would require MD query – no laterality (can nsg prompt MD for this info), site of OA, persistence level of asthma, stage of CKD 21
Rockport Post Impl ICD-10-CM

22. CDI/MD Query Process Different methods: Via telephone orders
Via progress notes
Use of “query” form
*must have supporting MD documentation in chart!
Make sure any documentation received from MD clarifying their diagnoses includes MD signature and date
Keep documentation as part of the legal record 22

23. Query Forms to Include the Following:
Resident name
Admission date/date of service
Name of physician/provider to whom the query is directed
Medical record number
Date of the query
Name/contact information of person initiating the query
Statement of the issue
Site the clinical documentation from the medical record supporting the need for query (if any)

24. Statement of the Issue
Provide the practitioner/MD the reason for querying:
Ask the practitioner to make a clinical interpretation of the facts in the medical record
May be written as a question
Several choices should always be given, including a choice of “other, please specify”, “unable to determine” and “clinically irrelevant”
Check boxes are ok
Should not sound presumptive, directing, prodding, probing or as though the practitioner is being led to a diagnosis

25. Poor MD Query
Introduction of new information not documented is inappropriate
Cannot be seen as “leading” the MD in a certain direction
Leading = when the expected answer is in the query
Example: “Doctor, in your progress notes you show a down arrow after the abbreviation Na, for sodium, do you mean hyponatremia?”

26. Poor MD Query
Presumptive = using your own clinical knowledge to determine the diagnosis
Example: “Doctor, the U/A shows a bacteria count of over 100,000 and antibiotics were started on admission, giving a clinical picture of a UTI. If you agree please document this diagnosis”

27. Good Queries Provide the Facts
Example: “Doctor, in your progress note dated Dec14, you document anemia and you ordered patient to ER for transfusion of 2 units of packed cells”. Could the anemia be further clarified as:
1) acute blood loss anemia;
2) acute-on-chronic blood loss anemia;
3) anemia due to chronic disease;
4) other, please specify;
5) unable to determine;
6) clinically irrelevant

28. How to Query?
Identify diagnoses that need more information to assign a correct ICD-10 code
Decide what format will you use for MD queries
Decide what is the best way to obtain MD response 28

29. Sample query
Reason for query: Doctor, the order for Clopidogrel is indicated as being used for chronic DVT, yet there is no physician documentation to substantiate this. Can you please clarify the reason for use:
_____ Chronic DVT
_____ Heart disease prophylaxis
_____ Stroke prevention prophylaxis
_____ Peripheral artery disease
_____ Other, ____________________________

30. Diagnosis Complete and Specific – Admission Review
Review of diagnosis list (on skilled residents) for all current diagnoses and supporting documentation – i.e.,
Recent surgeries while in hospital; look for acute operative reports
Specificity of the diagnoses to include laterality, complication documentation;
More specific diagnosis ‘explanation’ where applicable
MDS/J2000 prior surg in last 100 days w/active tx or J2100 recent surg last qual stay? If so, should have aftercare following surg code - Z47 or Z48
Do you suspect a complication, but there is not clear MD documentation? Guidelines indicate there must be MD documentation that supports coding of a complication

31. Licensed Nursing Assist
LN are able to give us information regarding treatment of ulcers for staging and severity
LN should be obtaining COMPLETE orders
New antibiotic orders include condition and site, if needed
New treatment orders include condition and site
New medication orders include correct condition being treated

32. RD Assist Assess new residents for malnutrition risk factors
If BMI is > 35 and resident has obesity related conditions, are we prompting MD for obesity related documentation?
If BMI is 40 or above, do we have supporting MD documentation of obesity?

33. Supporting MD Documentation
Supporting assessment and documentation – Clinical Assessment – H & P, Progress notes
History And Physical completed within 72 hours with documentation/diagnosis and treatment plan that supports the skilled nursing level of care for Medicare coverage
Progress Notes– that meet the focus of assessment of the individual, findings and plan of care

34. The Physician Documentation is Key to PDPM
Discharge Summary timely on transfer from acute
Issue for the physician if not sent to the facility at transfer or all the information is not in the transfer packet
Facility Interoperability of information from the hospital can assist the physician in correct and complete documentation

35. CMS Medicare Promoting Interoperability Program Scoring Methodology for 2019
Why hospitals will be motivated to exchange data with the SNF:
Health Information Exchange portion:
The scores for each of the individual measures are added together to calculate the total Promoting Interoperability Program score of up to 100 possible points for each eligible hospital
Support Electronic Referral Loops by Sending Health Information = 20 points
Support Electronic Referral Loops by Receiving and Incorporating Health Information = 20 points
On August 2, 2019 CMS published the Fiscal Year (FY) 2020 Medicare Hospital Inpatient Prospective Payment System for Acute Care Hospitals and Long-term Care Hospital Prospective Payment System Final Rule. 

36. When is a Query Needed?
Clinical Diagnoses and assigned ICD-10 codes driving Reimbursement
New Patient Driven Payment Model specifies which diagnoses can be used for reimbursement with the CMS Mapping Tool
SNF needs specific, accurate diagnoses that may increase their reimbursement
Incomplete, conflicting diagnoses may result in decreased reimbursement and /or denied claim
CMS is increasing claims reviews and accountability measures to support billing based on diagnoses selected, coded and billed

37. Diagnoses Complete and Specific
Principal diagnosis:
Primary reason for coverage
H & P, Examinations, progress notes and supporting documentation from Physician support selection of diagnosis
For a condition treated in the hospital stay immediately preceding admission to the SNF
What’s new? Many diagnoses used prior to the implementation do not map = SNF CANNOT use vague diagnoses for the Principal Diagnosis for Medicare A Coverage
Be aware! Just because a diagnosis maps does NOT mean it should be used as a primary diagnosis!
Example – Acute CVA I63.9 maps, but per coding guidelines this code does not reflect correct coding practice for LTC. Should always code the residual effects of the CVA.
Make sure on readmissions that you have the correct primary!

38. Diagnoses Complete and Specific -2
Secondary Diagnoses – 9 diagnoses + other Diagnoses
The most significant conditions to support skilled care and treatment
Justify Medicare/skilled coverage
Medications and Treatment conditions
Comorbid conditions
Support services/billing
What’s new? Accurately capturing secondary diagnoses under PDPM can significantly impact Medicare A reimbursement
Obesity does not map as NTA; however, morbid obesity does map = increased $$
Additional diagnoses to support medication/treatment services – which may or may not contribute to Part A Medicare coverage

39. PDPM Coding
What is coded on the MDS could vary from the diagnosis list if
MDS/ARD is set to look back into the hospital stay
Some items that were treated at the hospital but not treated at the facility could be captured
Sepsis
Fever and vomiting, feeding tube…
Parenteral/IV feedings
Know the nursing categories (extensive services, special care high, special care low, clinically complex, behavior symptoms/cognitive performance, reduced physical function)
Use the CMS PDPM Calculation Worksheet for SNF’s

40. What We Need From the Physician
To identify the conditions
That are not resolved and are active diagnoses
Any chronic conditions that are still active (treated in the last 7 days)
Clarify
Diagnoses
Any conflicting documentation related to a diagnosis

41. ICD-10 Coding of Diagnoses for PDPM
Medicare has been paying claims with Principal Diagnosis codes that break coding rules, but this incorrect coding will be rejected with PDPM
CMS PDPM Clinical Category Mapping identifies those diagnoses that may be used as a principal diagnoses for Medicare
The patient’s clinical category classification then factors into the PT, OT, and Speech & Language Pathology (SLP) case mix indices
Some diagnoses in Non-Therapy Ancillary/NTA and Speech Language Pathology/SLP categories also have specific diagnoses that must map (ones that must appear on MDS/I8000)
Clinical category, NTA and SLP comorbidity diagnoses all affect the overall PDPM reimbursement rate
*be careful, mapping does not follow all coding rules

42. ICD-10 Coding of Diagnoses for PDPM-4
Facilities must use ICD-10 principal diagnosis codes that aren’t listed as
“Return to Provider” in the CMS PDPM Clinical Category Mapping tool
Many diagnosis codes for unspecified or non-specific diagnoses do not map
Usually lacking laterality
Cannot be used for Medicare Principal Diagnoses
May need to query the physician to obtain more specificity

43. Evaluation and Management – The Physician & PDPM - What does that mean?
Besides the Facility’s Medicare Coverage For Skilled Part A Stay –
Three key components when selecting the appropriate level of E/M services provided are
History
Examination
Medical decision making
MD billing but includes doc from your facility

44. Evaluation and Management – The Physician & PDPM - What does that mean
The Medical Plan of Care; the Complexity of that Plan also drives the E/M Code the physician uses and bills with
Supports the complexity/time required for evaluation of the resident by the physician; nature and amount of work required by the physician
Treatment plan that meets the resident “skilled service needs” that is provided by the facility skilled staff, nursing, therapies, other treatment providers
Specific Diagnoses for care, treatment and Insurance/Medicare/HMO/ACO coverage

45. Evaluation and Management – What Does That Mean in Terms of PDPM?
EQUATES to the
Level of skilled care the resident requires
YOUR Plan for Services
FACILITY Plan for Services
BILLING FOR THE SERVICES
FOR THE FACILITY
WHAT YOU CAN BILL

46. What Does PDPM and E & M Mean to the Physician?
Levels of Evaluation and Management
E & M Codes will be determined based on the review of history and examination
Compare the facility’s diagnosis listing derived from documentation available
Review of the Diagnosis for PDPM coverage
Add any additional diagnoses based on the examination and desired treatment plan for the skilled services.
Reflects the extent and nature of the visits; the comparative physician’s updated H & P or new H & P (if a newly assigned physician); notes, support for the physician visit at the E/M level

47. E/M SERVICES BASED ON THESE FOUR TYPE OF EXAMINATIONS
CONSISTENT WITH SERVICES PROVIDED UNDER PDPM
COMPREHENSIVE – Multi-system Exam of a single organ system (& other related body area(s) or organ system(s)
DETAILED – Extensive examination of the affected body area(s) or organ system(s) and other symptomatic or related body area(s) or organ system(s)

48. E/M SERVICES BASED ON THESE FOUR TYPE OF EXAMINATIONS
CONSISTENT WITH SERVICES PROVIDED UNDER PDPM
EXPANDED PROBLEM FOCUS –Limited examination of affected body area or organ system and any other symptomatic or related body area(s) or organ system(s)
PROBLEM FOCUSED - limited examination of affected body area or organ system.

49. Best Practice for Diagnosing and Assessing -For the Facility and the Physician
RELOOK
At the admission diagnoses provided from the hospital H & P and Discharge Summary
Diagnoses added on examination in the facility (facility H&P)
Identify the PRINCIPAL & SECONDARY DIAGNOSES and treatments requiring “Skilled Services”
Evaluate and document
Physician’s Orders to support care, treatment and reimbursement

50. Complexity of the Examination
Gives guidance to the E/M Code used/support for Skilled Care.
Consider not only the complexity of the examination, but also
The principal diagnosis
Related diagnoses/conditions and treatments requiring skilled services

51. The Facility to Assist MD With …
At admission of a skilled resident, the Admissions/MDS Nurse/Clinical Team/Health Information Record Designee will:
OBTAIN the acute hospital H&P/discharge summary/ operative/procedure reports and/or type surgery & have available upon resident transfer to the facility;
Review any additional documents that arrive post admission (for any additional diagnoses)
Identify all active diagnoses from the above documents

52. The Facility Will
Prepare a diagnosis worksheet; make sure all active diagnoses/conditions are listed; made available for review.
Sequence the active diagnoses and select the primary reason for skilled coverage and code using the ICD-10 book and Coding guidelines
Identify any diagnoses needing MD clarification with specificity, laterality, or conflicting documentation, addressed per ICD-10 coding requirements/CDI
FOLLOW UP WITH MD/NP/PA for any clarification or additional documentation needed

53. The Facility Will Assist You … -3
Diagnoses (for Medicare A) have assigned ICD-10 codes reflective of PDPM
Whenever diagnoses are updated in the computer (if manual or hybred):
New facesheets are printed
Old Facesheets are removed/New Facesheets are placed onto the chart.
Physicians should have a copy of the diagnoses that are used in the facility and supportive of the reasons for Physician’s visits = Physician’s billing from their offices needs to have same diagnoses.

54. The Facility Will Assist You … -4
e-Sign and Provide Documentation for Clarification of Diagnoses may be obtained by
System generated E-Sign Physician Queries/Clinical Documentation Improvement (CDI), Orders
If the computer system/s allows
Physician has completed an attestation statement as part of the credentialing process or update to the credentialing process
Separate form or format in the e HR
Part of a physician’s order format on paper or in e HR
Other methods for obtaining Physician Query
Fax Query form to the MD
Telephone Order clarifying the medication or treatment and the condition
Structured progress notes, etc.
PCC App w/MD has progress note capability that links with e hr

55. Capturing Significant Diagnoses
PDPM Reimbursement based on patient acuity with increased reimbursement based on diagnoses documented by the physician
Non-Therapy Ancillary Category (NTA)
Diagnostic categories and clinical support services needed for patients more medically complex or that demonstrate a higher acuity
Must obtain pertinent patient information with discharging hospital and SNF attending MD to accurately capture all appropriate NTA items
Document diagnoses on H&P/Progress Notes or certain medications/treatment orders can obtain an NTA Comorbidity Score if PDPM category criteria met
Significant Reimbursement Impact

56. MD Query Examples NTA Category
Obesity - Specific Diagnosis needed to capture NTA comorbidity
BMI 40 or greater identified by Dietitian
BMI of =/>35 and is experiencing obesity related health conditions si.e. High Blood Pressure/Heart Disease, Diabetes Mellitus Type 2, Sleep Apnea, Depression, Urinary Incontinence, or 100 pounds above IWR.
MD must document the significance of high BMI (as stated above) or obesity related conditions
Malnutrition/PCM Protein Calorie Malnutrition
BMI < 18 (or < 22 for the elderly)
Presence of pressure ulcers
Poor intake < 50% over last week
Significant weight loss
< 80% Ideal body weight
Obesity related conditions?
Malnutrition risk factors?

57. MD Query Examples-2
Complications of device implant or graft if complication is suspected, but without clear MD documentation
Seizure Diagnosis vs Intractable Epilepsy – when medications are not effective in controlling Seizures
Increased reimbursement for Intractable Epilepsy
May be identified upon admission or after

58. MD Query Examples-3
CHF
Acuity – Acute, Chronic, Acute on chronic
Type – for example, Left ventricular failure, Systolic heart failure (HFrEF), Diastolic heart failure (HFpEF), combined, etc.
Fractures – specificity required to identify diagnosis and code
Type: Traumatic, Periprosthetic, Pathologic - Site, laterality
Routine healing, Delayed healing, Non-union, Mal-union
Sepsis - Active diagnosis based on current symptomology?
Identify active vs resolved
Sepsis criteria met?

59. Physicians Documentation to Support PDPM
Assessment of the Resident
H & P, progress notes and Discharge Summary from Acute and the skilled facility supports the level of Medicare covered service at the PDPM level with appropriate Principal and secondary diagnoses and comorbidities
Resident needs skilled nursing services and the level of the Evaluation/Management Codes i.e., E/M should support that complexity of health care assessment and services

60. Recap Physician Facility Facility H&P within 72 hours of admission
Diagnoses complete, specific
Support the need for skilled nursing services which may also include Therapies
Respond to diagnosis queries from SNF
Facility
Ensure correct/complete coding is occurring
Obtain/have available clinical information from the transferring hospital
Prepare diagnosis list and print face sheet with current diagnoses
Query Physician when addition information needed to obtain accurate, current diagnosis