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ABCHospital

Health Information Management Services

Policy/Procedure

Manual: Health Information Management Services / Subject: Physician Query Policy
Prepared by: Coding & CDI Manager / Effective Date:
Approved by: / Revised:
Reviewed:

I.PURPOSE: To establish guidelines for inpatient Physician Queries at ABCHospital.

II.POLICY:

  1. The overall goal of query activities is to clarify ambiguous, conflicting, or incomplete documentation to promote the overall quality and completeness of clinical documentation so thatthe coding data set accurately represents the severity, acuity, and risk of mortality profile of the patient being treated.
  2. The following priorities will be implemented to most effectively employ resources focused on query activity:
  3. Accurate reimbursement for services rendered, complexity of care & resource utilization
  4. Accurate profiling (such as risk of mortality, length of stay and severity of illness).
  5. Improved specificity of coding data.
  6. Support documentation requirements needed for current, accepted professional coding practices & convention.
  7. Queries are utilized to clarify physician documentation whenever there is conflicting, ambiguous, or incomplete information in the medical record regarding any significant reportable condition or procedure.
  8. Reportable conditions are defined by Official Coding Guidelines as those that affect patient care in terms of requiring:
  9. Clinical evaluation; or
  10. Therapeutic treatment; or
  11. Diagnostic procedures; or
  12. Extended length of hospital stay; or
  13. Increased nursing care and/or monitoring.
  14. Clinically significant & reportable conditions in the newborn include those listed above as well as those conditions that have implications for future health care needs.
  15. As a result of the disparity in documentation practices by providers, querying has become a common communication and educational method to advocate proper documentation practices. Queries may be made in situations such as the following:
  16. Clinical indicators of a diagnosis but no documentation of the condition
  17. Clinical evidence for a higher degree of specificity or severity
  18. A cause-and-effect relationship between two conditions or organism
  19. An underlying cause when admitted with symptoms
  20. Only the treatment is documented (without a diagnosis documented)
  21. Present on admission (POA indicator status)
  22. Only qualified individuals (including those professionals in the Coding, CDI and Physician Advisor roles)will be allowed to perform the query process who have strong competencies in the following areas:
  23. Knowledge of healthcare regulations, including reimbursement and documentation requirements
  24. Clinical knowledge with training in pathophysiology
  25. Ability to read and analyze all information in a patient’s health record
  26. Established channels of communication with providers and other clinicians
  27. It is appropriate to generate a physician query when documentation in the patient’s record fails to meet one of the following five criteria:
  28. Legibility
  29. Completeness
  30. Clarity
  31. Consistency
  32. Precision
  33. Queries are submitted in an approved written format (with the occasional exception of CDI queries which may be verbal during the patient’s stay or immediately after discharge) and may be generated in one or more of the following ways:
  34. Concurrent (while patient is still an inpatient)
  35. Post-discharge
  36. Post-bill
  37. Verbal queries will have a written summary recorded of the conversation as soon as practical following the query.
  38. A query will include the following information:
  39. Patient name
  40. Admission date and/or date of service
  41. Health record number
  42. Account number
  43. Date query initiated
  44. Name and contact information of the individual initiating the query
  45. Statement of the issue in the form of a question
  46. Clinical indicators and/or short quotes of existent documentation specified from the patient’s record
  47. Queries will not be posed with a yes / no response (with rare specific exceptions such as querying for the status of a possible diagnosis to determine if the diagnosis had been ruled in or ruled out).
  48. Multiple choice formatting of responses are acceptable and will include the following:
  49. At least 2 clinically reasonable options
  50. “Other, Please Specify: ______”
  51. “Clinically indeterminable”, “Unable to further specify”or equivalent wording.
  52. Queries must be written with precise language, identifying clinical indications from the health record and asking the provider to make a clinical interpretation of these facts based on his or her professional judgment of the case.
  53. The query format should not sound presumptive, directing, prodding, probing, or as though the provider is being led to make an assumption.
  54. CDS queries will be retained as a part of the administrative record but are not part of the Legal Medical Record. As such, to be able to capture responses to CDS queries, there must be documentation in the legal medical record (progress note, discharge summary, addendum, etc.).
  55. Queries presented by Coding professionals are part of the Legal Medical Record and physician responses through the query form stand as part of the information available to determine final coding.
  56. Queries will be designed to be in accord with recommendations as provided in “Managing an Effective Query Process” published by the American Health Information Management Association (AHIMA).

Reference:

  • AHIMA. “Managing an Effective Query Process” Journal of AHIMA 79, No. 10 (October 2008): 83-88.
  • AHIMA. “Guidance for Clinical Documentation Improvement Programs” Journal of AHIMA 81, No. 5 (May 2010): 45-50.