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January 7, 2008

The Query Quagmire
By Judy Sturgeon, CCS
For The Record
Vol. 20 No. 1 P. 4

Hospitals nationwide are wrestling with the new regulations for diagnosis-related group (DRG) assignment and reporting whether inpatient diagnoses were present on admission (POA). The changes in conditions that qualify as secondary diagnoses affecting payment—and addition of the POA criteria—have resulted in a need to revise current query forms or create new ones.

In early 2001, the Centers for Medicare & Medicaid Services (CMS) objected to the use of query forms as official medical record documentation when their quality improvement organizations (QIOs) were auditing charts for DRG validation. It reconsidered this directive a few months later and allowed the use of the form “to the extent it provides clarification and is consistent with other medical record documentation.” This creates a potentially sticky situation for those assigned to the task. To avoid being caught in a compliance quagmire, there are several concerns involved with this process that must be considered before a facility approves or uses this type of document.

Compliance takes priority in creating any type of standard query form because the response can often affect the final DRG and payment to the facility from Medicare and other payers. Careful phrasing is important for questions to the medical staff; they must not lead or prompt the physician to use specific terminology to increase the payment. For instance, an inappropriate question would be the following:“Dr. X, if this patient had acute blood loss anemia, it would increase the hospital payment by $2,000. If the patient had this diagnosis, please document in the discharge summary.” This is a blatant incentive to document the diagnosis for the offered $2,000 carrot. Even a more subtle approach that says, “Acute blood loss anemia is a CC [complication and comorbidity]; please document if correct,” can be considered too leading.

The query also shouldn’t introduce information that is not already documented in the chart or hasn’t already been considered by the physician. Consider the following example: “Dr. X, this patient had a urinary tract infection [UTI] in the emergency department visit when I coded that case last week. If he is still taking antibiotics, could you please document the UTI?” If the prior diagnosis had no documentation in the current case and is not affecting care on this encounter, both basic coding rules for including secondary diagnoses and the CMS guidelines on appropriate query format can create a barrier to using this type of request.

Finally, the reply must be documented as a permanent part of the patient record. The coder cannot e-mail a question to the physician, receive an e-mail response, and then code the chart based on the e-mail alone. Even if the coder documents on the coding summary that the doctor clarified via e-mail, this is insufficient support to include a code for the new diagnosis or procedure information.

Not all facilities include the query form in the final chart; some queries are verbal, some electronic, and some are still in hard copy. However, in all cases, the physician must formally document a reply in the chart, either in the concurrent notes and dictation or as a postdischarge addendum. Any additional information needed to support the clarification should be included along with a complete signature and the date and time of the documentation.

These criteria must be considered when dealing with the physical issues and practical considerations of getting the questions to the doctors and responses in the charts. Details will be affected for utilizing a query process with a paper vs. an electronic chart. Availability of a compatible process should be considered when implementing any electronic medical record for the facility; the HIM department will be involved in approving any permanent chart forms whether they are finalized electronically or as hard copy.

Practical applications to take into account include the use of internal or external e-mail security in the case of off-site physicians or coders. It is likely that institutional policies already exist in this area and must be considered when setting up the most efficient method of contacting the medical staff. Telephones and text messages present physical and security considerations. If your staff is fortunate enough to meet one on one with the doctor, getting the reply into the chart can be the challenge. It’s easy enough to get agreement in a conversation; it’s another thing altogether if the chart is not there at the time of the conversation.

Policies and procedures for the use of query forms—and approved formats for the forms themselves—can be created from scratch or modeled after those already available in the industry. Forms can be purchased from a number of vendors or created in-house; in either instance, it is imperative that the final selection be reviewed and approved by those most involved in and affected by their use.

Physicians are more likely to respond to queries if the format doesn’t interfere with patient care or their normal processes and practices. Requesting their input for the type of query that they prefer prior to implementing the process will go a long way toward ensuring their long-term cooperation.

Coders should review the information requested on recurring query forms and verify that the question will result in documentation affecting the final DRG. For example, asking a physician if he debrided down to vitalized tissue is well and good but does not specifically address whether the procedure was truly excisional in nature. Abrasive techniques, water jets, and scraping a wound with the edge of a curette can all remove devitalized tissue but are still not coded as excisional debridement.

If utilization review staff will be handling the query process, their relationships with the facility physicians can be vital in contributing to the effort’s success. While medical staff may be inclined to consider coders as part of the “medical record police” and be resistant to their requests, the nursing staff in the utilization review department may be viewed as clinical partners and peers to physicians. This certainly is not always the case but neither is it uncommon, and any edge that can help the revenue cycle complete the claims process in a timely manner is certainly advantageous to all.

Once the players in the effort have been identified and recruited, a policy and procedure for the format and placement of queries is typically developed. Since many sources are available as basic guides, it is not necessary to reinvent the wheel.

Several Web sites, including the TMF Health Quality Institute’s comments on the subject found here, can be used as resources. You can also Google “CMS physician query form.” In addition, the AHIMA has published a practice brief specific to this effort on the TMF Web site.

The setup and players may vary from facility to facility, but the end result should be the same. Greater specificity in a chart translates not only into more correct coding and payment—the improved information enables better care by everyone who treats the patient—severity of illness and risk of mortality can be reported more accurately due to increased detail on diseases and procedures, and subsequent encounters will have more medical history from which to make new treatment decisions. Ultimately, continued improvement in care and patient satisfaction benefits everyone involved in the healthcare process.

— Judy Sturgeon, CCS, is the hospital coding senior manager at The University of Texas Medical Branch in Galveston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and appeal management for nearly 20 years.