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Establishing a Formal Physician Query Process

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The purpose of establishing a formal physician query process is a step in the right direction for obtaining accuracy and integrity in reporting coded data. A necessary component in any compliance plan is the assignment of correct codes in a timely fashion with the assistance of a formal physician query process. To ensure data quality and produce accurate coded data the querying of physicians and healthcare providers is necessary. A query is used to initiate communication from providers for clarification or additional information not completely or consistent as documented in the patient's medical record. This process is not a substitute for appropriate documentation, but is a tool to effectively ensure the provider documentation meets coding compliance standards.

 

Documentation provided by physicians, providers and other caregivers responsible for patient care are required to work jointly with the coding department to follow the ICD-9-CM Official Guidelines for Coding and Reporting by submitting complete, consistent and accurate documentation for code assignment. Another purpose of the querying process is to make sure that the documentation in the patient's record reflects accuracy, meets medical necessity, appropriateness of quality of care and supports reimbursement. The query process is also necessary to confirm conflicting or ambiguous documentation.

 

Inaccurate and incomplete documentation results in the use of nonspecific and unspecified codes, impacting data integrity, reimbursement and compliance issues.

 

There are two types of queries: retrospective and concurrent. A retrospective query is performed after discharge or pending claims submission to review information that is lacking in the medical record. The concurrent query is an ongoing process in which the provider's documentation is screened and is queried for clarification or additional information required for coding while the patient is still in-house.

 

Queries should be initiated in writing utilizing a standard form representing the type of clinical information being requested. A standard and approved query format should be used that is approved by the organization's leadership, only approved query forms will be used.

 

Query format

Each query must contain information that properly identifies the patient and the encounter that is the source of the query. An established policy regarding the format of the query is recommended.

 

A query should contain at a minimum:

  • Patient name
  • Admission date (date of service)
  • Medical record number
  • Account number
  • Date query initiated
  • Name and contact information of the initiator of the query
  • A statement of the issue (list clinical indicators from the chart or ambiguous/unsubstantiated information)

 

Coding guideline and resources

The following information is required to assist coding staff for a query process:

  • ICD-9-CM Guidelines for Coding and Reporting
  • American Hospital Association Coding Clinic
  • CPT Assistant
  • CMS Correct Coding Initiative (CCI).

Monitoring and auditing

Queries should be reviewed retrospectively to ensure completion according to the documented policy. A representative sample of the total monthly queries should also be audited for necessity, language, requested information and responses.

 

Audits of individual provider queries should be conducted in an effort to improve health record documentation and to identify high risk compliance issues and patterns of inadequate documentation. The results of these audits will provide opportunities for provider documentation education.

 

Queries are deemed appropriate when documentation in the patient's record fail to meet the following criteria:

  • Clarity — Diagnosis listed without statement of cause or suspected cause. Procedures not clearly documented to the suggestive documentation implied by CPT lay descriptions.
  • Completeness — Entries to the patient record that do not correlate with clinical indicators or diagnostic tests.
  • Consistency — Information documented that conflicting, or not substantiated.
  • Correctness — Instances when clinical reports suggest a need for more specific documentation.
  • Legibility — Illegible handwritten notes where the data cannot be assessed for coding.

 

Queries should not be used to question a provider's clinical judgment, and may only be used to clarify documentation when it fails to meet criterion. Providers should only be queried when documentation is conflicting, ambiguous or incomplete regarding any significant reportable diagnosis or procedure.

 

Providers are expected to follow medical staff bylaws and assist in providing documentation indicated by the query policies and procedures. Timely response with documentation that is complete and specific is required.

 

Coding staff performing the query function are expected to follow policies relating to documentation, querying, coding and compliance. A query should not be performed for every discrepancy in the medical record, insignificant and irrelevant findings do not require a query, and the value of collecting information for improved data is the primary objective of the query process.

 

Queries are initiated for all payor types regardless of the impact on reimbursement. Coders should not perform unnecessary or leading queries. The practice of repetitive querying or overuse of the query process should be monitored internally.

 

Standard wording for a non-leading physician query

  • Wording should be appropriate to obtain correlation between diagnoses or between diagnosis and diagnostic/therapeutic procedure results without leading.

 

  • Appropriate wording is required for clarification of documented entries soliciting but not leading, for the most specific information required for code assignment.

 

  • Appropriate wording is required to obtain additional information that is not clearly documented by the provider or resolve conflicting information. New information should not be introduced by the coder.


Retention of queries

There are no retention standards for query forms. Permanence and retention of completed queries should be at the discretion of the organization's policy. The policy should indicate if the query is made part of the patient's permanent record or stored as a separate business record. The form should be readily available for audits, monitoring and compliance.

 

Benefits of a query process

The process of querying providers is an essential mechanism to improve data quality, documentation and resolution to reimbursement issues. This process is also an effective approach to obtaining complete and concise information as required for coded data. Patterns of poor or inadequate documentation can be identified and addressed with provider education and training.

 

An effective query process will bridge the gap of communication between coders and providers. This process is a winning solution for physicians, coders and healthcare organizations.

 

By implementing an effective query process facilities are likely to demonstrate improvements in the quality of coded data and meet the needs established for compliance.

 

The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.


References

1. AHIMA. "Managing an Effective Query Process" Journal of AHIMA 79,(October 2008):

 

2. AHIMA, "Health Information Management Compliance: A Model Program for Healthcare Organizations" Journal of AHIMA, 2002

 

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