January 18, 2010

Escape Query Quandaries
By Alice Shepherd
For The Record
Vol. 22 No. 1 P. 10

Several strategies, including implementing electronic systems, can make life easier for coders looking to obtain clear, accurate documentation.

The inpatient prospective payment system introduced in 1983 bases hospital payments on inpatient diagnoses and procedures, thereby linking physician documentation to coding and diagnosis-related group (DRG) accuracy. Because coders are forbidden to make assumptions concerning discrepancies in the documentation, they need to query physicians for clarification of any unclear or ambiguous statements. Unfortunately, physicians often don’t answer such queries in a timely manner, which may delay billing and place financial burdens on hospitals.

The Trouble With Queries
“The rules that dictate what can be coded from a chart are not necessarily clinical, and physicians are not usually trained to navigate them,” says Andrew Rothschild, MD, MS, MPH, FAAP, CCDS, an associate director with Navigant Consulting, Inc who trains physicians on documentation. “This makes it extremely important that knowledgeable HIM personnel query the doctors to ensure that codes will accurately reflect the clinical picture.”

Tray Dunaway, MD, a keynote speaker and trainer for healthcare organizations on topics ranging from coding and documentation to marketing and quality, recognizes the need to seek out doctors. “The query process is essential because physicians don’t know what documentation is important in the chart,” he says. “The problem is many physicians are not clued in to the process and discard queries as a distraction. They don’t realize that helping HIM ensure accurate coding is a win-win for both parties.”

Sometimes the reason physicians don’t respond to a query is because, in their mind, the chart is clinically clear. For instance, a doctor has prescribed twice-daily maintenance fluids for a patient whose lab values indicate severe dehydration, but the word “dehydration” is never mentioned. “Unless the physician uses the term ‘dehydration,’ the coder is not allowed to assume that diagnosis and has to query,” says Rothschild. “The physician so queried may assume that the coder is incompetent for not recognizing the signs of dehydration.”

Queries also become necessary when doctors use slang that is not codable. “As a pediatrician, I might say, ‘the patient was grunting,’ often meaning he or she was in acute respiratory failure, which is a very high-severity diagnosis,” says Rothschild. “Another term commonly used by physicians, but not reflected as severe in coding, is ACS (acute coronary syndrome), which is often used to indicate an acute myocardial infarction (AMI, or heart attack). In coding terms, a patient who presents with an AMI will not have had that heart attack until the doctor writes ‘acute MI’ in the chart. The more common term ACS may lead to coding as simple angina (cardiac chest pain) unless the coder queries the physician. ACS codes to a 1.9-day length of stay, while a patient with an acute MI with other secondary diagnoses might have a 12-day stay. The hospital loses money and the doctor looks inept because a seemingly low-severity patient had a very long stay. If the patient dies, it will appear that he died without having a serious illness.”

Queries are also necessary because doctors like to generalize, explains Rothschild. Pneumonia, for instance, could be aspiration pneumonia—a highly weighted, serious diagnosis—or simple viral pneumonia, which may not require a hospital stay.

Coding inaccuracies are particularly serious when they seem to suggest fraudulent billing practices. The Fraud Enforcement and Recovery Act of 2009, which updates the False Claims Act, extends liability for fraud (even when unintentional) to both physicians and hospitals. Rothschild cites the following example: “I saw a chart in which a coder had coded a dissecting aortic aneurysm, which is an extremely severe illness with a very high mortality rate. Upon reviewing the chart, I noticed that the patient went home the same day. I found that the physician had used some slang, which was misinterpreted by the coder as a dissecting aortic aneurysm. If a hospital is incorrectly reimbursed for something that should have been recognized as untrue or inappropriate, then it’s considered fraud. The vast majority of apparent fraud is unintentional.”

Closing the Gap
Dunaway says changing physicians’ behavior works only if their beliefs are altered first. “Hospitals usually tell physicians that they need to improve their documentation so the hospital can do better on DRGs. The problem is they don’t translate those benefits into physician benefits, so physicians couldn’t care less,” he explains. “If you can show how improved documentation will make money for physicians, save them time, alleviate stress, and give them credit and recognition, it changes their perception. They no longer view the person making the query as a nag or a bother but as a resource they can use to benefit themselves and the hospital. Once that shift occurs, the physicians pay more attention to their documentation and will be rewarded in kind.”

Dunaway recommends identifying and training a knowledgeable documentation specialist to develop relationships with physicians and educate and train them on the documentation process and the need for queries. But who is best suited for this role? “Coders are sometimes intimidated by physicians, so it has to be someone who is not afraid to have an open discussion with a doctor,” he says. “The ideal person to interface with a physician as a documentation specialist might be an experienced OR nurse who already has the doctors’ confidence. Nurses can straddle the difference between the clinical aspects of documentation and the business, quality, and regulatory aspects. The nurse would need to be given clinical documentation-specialist training by HIM.”

Nurses or other clinicians chosen to interface with physicians would need to be well versed on DRGs, as well as evaluation and management (E/M) coding, to position themselves as a resource to physicians in both areas. “One of the key components of E/M coding is the documentation of multiple medical diagnoses, which in turn spins off the DRGs,” says Dunaway. “It’s a point of commonality that drives not only the DRG engine but also the E/M engine. The latter feeds the physician directly, while the DRG engine feeds the physician indirectly through quality. A documentation specialist that has a working knowledge of both will be seen as a true resource by physicians.”

Streamlining Queries With Technology
In October 2008, Beth Israel Medical Center’s Petrie Division Manhattan Campus deployed Meta Health Technology’s electronic physician query application, which is integrated into Meta’s coding and abstracting system. Raymond Cosner, RHIA, the facility’s assistant vice president of HIM and credentialing services, explains how the system works. “When a coder sees a need for a query, that information is fed electronically to our DRG coordinators who are ultimately responsible for reviewing the query, along with the chart, to ensure it’s a valid and proper query,” he says. “If the query is valid, the DRG coordinator uses the query application to send an e-mail notification to the physician containing a link to a secure site. Physicians review the query and communicate back to the DRG coordinator. If they agree with the query, they can add documentation electronically and send it back. They can also reply to the DRG coordinator’s message by asking for further clarification of the query. Or they can respond by stating they are unable to clarify based on their knowledge of the patient’s condition.”

All querying is currently done postdischarge, but Beth Israel is considering rolling out the system to a concurrent module to improve documentation while physicians are treating patients.

The DRG coordinator follows up on queries as appropriate depending on the response. For instance, if the physician provides additional electronic documentation, the DRG coordinator prints the electronically signed addendum and places it in the medical record. DRG coordinators are ultimately responsible for finalizing the coding, but information is shared with the coders so they are aware of the final result.

Prior to implementing this technology, all querying was done via telephone or notes on the chart or by tracking down doctors in offices and hallways. “It was a lot of wasted time,” says Cosner. “Our physicians asked for a more uniform and efficient method. In the past, we had a single-digit to double-digit response rate to our queries. Now the response rate is in the mid-70s overall and close to 99% for our hospitalists who receive about a third of our queries. The hospitalists are employees, so we have more control over them than the voluntary staff in terms of their use of the hospital’s e-mail system and the amount of time that they actually spend within the hospital. Although there is still room for improvement, it was a very successful implementation.”

Beth Israel’s HIM department provided formal training on the application to coders, DRG coordinators, coding managers, and supporting IT staff, as well as a subset of physicians who were frequently queried. “With about 2,300 physicians on staff, it would not have made sense to train everyone initially because you don’t know whom you’re going to query,” says Cosner. “If a physician is not queried for several months, he or she would forget the training in the meantime. Instead, each query e-mail notification provides a link to a user guide for the physician query application to serve as a kind of online real-time training. We also offer hands-on training in physicians’ offices when necessary. Physicians like the application. We have many senior attending physicians who, once they’ve bought into the technology, love it.”

The application automatically issues reminder e-mails for unanswered queries at user-determined intervals, removing the follow-up burden from the HIM department. Eventually, a physician who receives constant reminders will answer the e-mail, pick up the phone, or come to the HIM department. On rare occasions, HIM staff still have to make a call or track down a physician.

Another benefit of the technology is that it serves to identify training opportunities. “The system allows us to track the types of cases we’re querying on, the physicians we are querying, and the coders who are querying,” says Cosner. “If we are constantly querying the same doctor or same group of doctors for the same types of queries, it helps us structure in-service training on proper documentation.”

Physicians who are enrolled in the pay-for-performance program are rewarded for having no outstanding queries or incomplete charts by becoming eligible to receive incentives, provided all other requirements are met. Those who persist in failing to answer queries may be penalized by not being allowed to admit new patients or schedule OR time.

The application has the capability to develop templates for frequent queries. “Some people prefer to use templates, others to use their own words,” says Cosner. “The system is flexible. From an HIM perspective, we want to show consistency, so we encourage the use of templates. That way queries look consistent to physicians regardless of which DRG coordinator is sending them.”

Accurate Documentation Benefits Physicians, Too
Whether the query process is electronic or manual, an effective way to change physician behavior is to identify physician champions who understand the need for accurate documentation and can solicit cooperation from their peers. At Beth Israel, Cosner’s HIM team selected two champions: a member of the hospitalist group to work with his colleagues and the medical director to interface with voluntary staff.

“Drug company data shows that the best way to influence physicians is to identify their leaders, present them with a compelling argument, including direct physician benefits, and then assist them to succeed,” says Dunaway. “Once the other physicians recognize how the process is benefiting those who have embraced it, they will want in on it, too.”

“A physician champion is essential to elicit the cooperation of the small percentage who are difficult to approach,” says Rothschild. “It has to be someone who is a respected peer and who can explain how the queries are not just ‘for the hospital.’ Accurate coding and billing benefits patients and physicians in many ways. For instance, Web sites such as HealthGrades.com rely on hospitals’ billings to grade physicians. Doctors who want to look good will have to help their hospitals bill correctly.”

— Alice Shepherd is a southern California-based business-to-business journalist specializing in healthcare topics.

Ten Keys to Writing a Successful Query
Andrew Rothschild, MD, MS, MPH, FAAP, CCDS, an associate director with Navigant Consulting, offers a systematic approach to composing compliant, effective queries:

1. Personalize inclusively. Address the query to a specific physician but also indicate clearly whether others can respond.

2. Provide the principal diagnosis, which may or may not be the subject of the query.

3. Add brief facts, quoting from the documentation to avoid sounding as though adding interpretations.

4. Avoid seemingly accusatory statements and divert likely perceived blame.

5. Leave a “way out” (eg, If possible, please specify…).

6. Politely request help. Don’t tell physicians they must do something, even if required by regulations.

7. Permit uncertainty (eg, ask for the suspected diagnosis or likely etiology).

8. Be specific. For example, rather than asking a physician to clarify the significance of a patient’s condition (which may result in the answer “very significant”), specifically ask for the associated diagnosis and/or the acuity of the diagnosis.

9. Leave questions open ended. Avoid yes/no questions, never ask leading queries (which imply the answer), and never write queries that could be construed to solicit an answer that benefits the hospital financially.

10. Close politely and list your name and phone number.

For further information on writing compliant queries, visit http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm#guidelines.

— AS