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April 2013

Improving the Query Process
By Susan Chapman
For The Record
Vol. 25 No. 6 P. 22

Highly anticipated and much needed according to some, updated guidelines on how to write a compliant physician query have been released.

In February, AHIMA issued the practice brief “Guidelines for Achieving a Compliant Query Practice,” a collaborative effort between the HIM organization and the Association of Clinical Documentation Improvement Specialists (ACDIS) involving six representatives from each organization who came together to help improve the physician query process and ensure more accurate health records.

Many in the industry are welcoming the practice brief’s arrival. Dee (Schad) Banet, RN, BSN, CCDS, CDIP, director of clinical documentation improvement (CDI) for Kentucky-based Norton Healthcare, notes that previous practice briefs issued by AHIMA in 2008 and 2010 were open to interpretation and often created confusion. “Queries should not be leading, but what does that mean? We needed clearer guidelines,” she says.

Such ambiguity prompted AHIMA and the ACDIS to respond. “Since 2008, I’ve been receiving questions about queries from ACDIS members,” says ACDIS Director Brian Murphy, CPC. “Those questions drove this new brief. Once it was crafted, the document was reviewed by AHIMA and the ACDIS advisory board. Additionally, a number of professionals looked at it before it was formally approved.”

The two organizations coming together proved fruitful, according to Kathryn DeVault, RHIA, CCS, CCS-P, AHIMA’s director of HIM solutions. “Anytime we can collaborate like this, particularly with queries, it’s a good thing,” she says. “It’s hard to ask a question of a physician without being leading, yet how do we not rehash the record and still remain compliant? Whenever we can bring best practices into the industry, it’s better, and this was a good process. We had physicians, nurses, and coders, who all had a lot of different opinions, coming together at the table.”

A Better Understanding
As stated in the brief, “The desired outcome from a query is an update of a health record to better reflect a practitioner’s intent and clinical thought processes, documented in a manner that supports accurate code assignment. The final coded diagnoses and procedures derived from the health record documentation should accurately reflect the patient’s episode of care.”

To achieve this goal, CDI staff and coders often need to request additional information from attending physicians, yet they must steer clear of leading queries—those that are unsubstantiated by clinical elements in the patient record and/or direct a physician to document a certain procedure or diagnosis—to remain compliant.

The updated practice brief offers guidelines on when CDI staff and coders should consider generating a query, including when the health record documentation is incomplete or inconsistent; describes clinical indicators without a definitive relationship to an underlying diagnosis; includes clinical indicators, a diagnosis, and/or treatment unrelated to a specific treatment or condition; gives a diagnosis without clinical validation; or is unclear regarding present-on-admission (POA) indicator assignment. It also provides numerous illustrations of both compliant and leading queries, which experts across the industry are finding beneficial.

“The leading query examples are definitely helpful,” says Charlotte Lane, RHIA, CCS, an AHIMA-approved ICD-10-CM/PCS trainer. “It can be challenging, for instance, when the physician does not include clinical indicators yet provides a diagnosis. It’s beneficial for CDI staff and coders to know how to ask the right questions and remain compliant.”

Traditionally, CDI specialists work on patient floors reviewing charts. If there are discrepancies between a patient and his or her health record—for instance, if there is treatment for something that has not been diagnosed—with these new guidelines in hand, HIM professionals and CDI specialists now have a more specific understanding of how they can best query a physician to clarify the record.

Murphy points out that the brief relaxes the requirement for yes/no questions. “Previously, staff only could ask yes/no questions about whether a condition was present on admission,” he says. “However, if a diagnosis is substantiated in the health record—on a radiology report, for example—but the attending physician hasn’t entered it into the health record, the CDI staff can now ask a yes/no question to clarify.”

While Lane praises this change, she also likes that CDI staff and coders now can provide physicians with other choices. “With the new guidelines, we can ask yes/no questions but should also provide other options, like ‘other’ or ‘clinically undetermined,’” she says. “These queries can be designed to help physicians who can’t make certain determinations because it’s not part of their respective specialties, for instance. And what we really want is for clinicians and physicians to have an easier time doing their respective jobs.”

Early Feedback
Experts agree that while the new guidelines are a great improvement, it is too early to tell what the industry response will be.

“In order for us to receive feedback, we have to see how the guidelines work in practice,” Banet says. “From a clinician’s standpoint, the feedback will be positive, as the new brief helps us do more things about the gray areas.”

Maribelle Kim, RHIA, executive director of HIM operations at SPi Healthcare, agrees: “So far, it’s a helpful tool. You can never have too many guidelines or examples. The brief is definitely clear and usable, especially for those coders who work from home and don’t have face-to-face access to staff.”

Those working in a hospital setting also should find the new information extremely useful. “We predict a very favorable response because this is exactly what coders and CDI staff need,” says Leah Taylor, RN, CCDS, a data integrity specialist and recovery audit contractor (RAC) coordinator for North Carolina-based Iredell Memorial Hospital. “CDI staff can take this brief and its examples to the floor with them to use them in everyday practice, which is the goal the committee hoped to achieve.”

Although the brief has been met with praise, experts do see some drawbacks, noting that there will be a learning curve as clinicians adjust to changes in the multiple-choice format. “And the yes/no query is more blatant than in the past,” Taylor says. “Clinicians have to get used to it. Still, I like that we can finally do a yes/no query, and I’m sure most clinicians will appreciate that too.”

Robert S. Gold, MD, CEO of DCBA, Inc, who already has been in discussions with representatives from the ACDIS about the worthiness of the new guidelines, offers a mixed opinion. “This practice brief is much better than the last one issued in 2008. A lot of people are happy to learn how to free up getting information,” he says. “People especially like the capability of asking for the diagnosis to be provided when no one named it but it is obvious that it was identified, worked up, and treated. And the capability of extending yes/no beyond the previous limit of POA is a definite advance.

“But there is still no clear definition of ‘leading,’ which I believe is creating a lot of dissent,” he adds. “To help with this and until we receive further clarification, I plan to continue telling my clients to define leading as asking a physician to document something that has no basis in fact in the medical record. This is definitely to be avoided at all costs.”

The Larger View
Besides benefiting the day-to-day operations of coders, CDI staff, and physicians, Lane says the more robust guidelines will help throughout the facility as organizations adjust to a changing reimbursement landscape. “Payers are moving away from fee-for-service toward the pay-for-performance model,” she says. “If you have patients who are really ill, they use more resources and have longer stays. It’s important for CDI and coding staff to query properly in order to capture severity of illness. This ensures appropriate reimbursement as well as accurate data for use by hospital leadership to plan for the future.”

Hospitals also must be prepared for RAC audits. “In the past, if a physician documented it, the coder coded it. Now, if it’s not supported in the record, a query can be generated. That’s the stuff that auditors are looking for when taking back the diagnosis,” Taylor says. “The rules have changed because of recovery auditors. We need to have the diagnosis substantiated and clearly stated.”

Because auditors also use the AHIMA guidelines, Taylor says it makes reimbursement resolutions a bit more straightforward. “So when we come back with an audit or a denial, we turn to the specific guideline, which we can use to appeal,” she notes.

RACs often specifically request queries, which are not necessarily part of the permanent medical record in all facilities but instead part of the business record. To resolve this situation and help hospitals be prepared for review, the practice brief offers guidance on how an organization should retain queries: “Each organization should develop internal policies regarding query retention. Ideally, a practitioner’s response to a query is documented in the health record, which may include the progress notes or the discharge summary. If the record has been completed, this may be an addendum and should be authenticated.”

The advice continues, “Organizational policies should specifically address query retention consistent with statutory or regulatory guidelines. The policy should indicate if the query is part of the patient’s permanent health record or stored as a separate business record. If the query form is not part of the health record, the policy should specify where it will be filed and the length of time it will be retained. It may be necessary to retain the query indefinitely if it contains information not documented in the health record.”

The brief further cautions that auditors may request copies of queries to validate their wording even if they are not part of the legal health record.

Although the ramifications of the practice brief and the queries it impacts are far reaching, the joint committee that created it had a simple goal in mind. “The whole point of this new practice brief is to make querying easier,” Murphy says. “In the past, there has been a culture of fear surrounding queries. Ideally, concurrent review of patient information by CDI staff before a patient is discharged is the time to clarify the record while the patient is still fresh in the physician’s mind. This practice brief gives CDI staff and HIM professionals the flexibility to query correctly and in a timely fashion to ensure the accuracy of the record for improved patient care, to reflect the proper severity of illness of the patient, and for accurate reimbursement.”

— Susan Chapman is a Los Angeles-based writer and author.