Physician Query Handbook released

I think we should throw a party. ACDIS  just released the first edition of the Physician Queries Handbook: Guide to Compliant and Effective Communication. I’m not kidding. I’m talking par-T-y. This book is that fantastic. And I was so lucky to I be able to work on it with four wonderful people:

• Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS
  

  Success in a handbook. Simple.

• James S. Kennedy, MD, CCS
• Marion Kruse, MBA, RN
• Lynne Spryszak, RN, CPC-A, CCDS

It’s got cool query audit tools and sample query policies and sample documentation clarification forms but it also outlines various guidances throughout the years and throughout the industry. It provides the pros and cons of verbal and written queries, outlines multiple methods to track query efforts, and offers pointers for conducting effective queries.

Here’s a sample from the book.

A non-leading query clarifies the specificity of current diagnoses and/or procedures based on relevant, pertinent clinical facts within the medical record, such as signs, symptoms, findings, and test results; the treatment rendered including clinical pathways specific to a condition/diagnosis; and the patient’s risk factors including the patient’s current stable conditions, past medical history, medications, and overall risk based on his or her total health status picture. According to the AHIMA physician query practice brief:

“Queries that appear to lead the provider to document a particular response could result in allegations of inappropriate upcoding. The query format should not sound presumptive, directing, prodding, probing, or as though the provider is being led to make an assumption.”

In the following examples of inappropriate queries, the CDI specialist does not give the provider any documentation option other than the specific diagnosis requested. The statements are directive in nature, indicating what the provider should document, rather than querying the provider for his or her professional determination of the clinical facts.

In the first example, the statement “the patient has anemia” may be presumptive, and the statement “please document ‘acute blood loss anemia’” is directive and clearly leads the provider.

In the second example, the CDI specialist inappropriately asks the physician to document chronic respiratory failure. In the third example, the CDI specialist introduces new information not previously documented in the medical record. This is also inappropriate in a provider query. If this diagnosis was not documented in the current admission and is not affecting the patient’s care, it does not meet the definition of a secondary diagnosis. Querying for this new information, which does not meet coding and reporting requirements, is inappropriate.

EXAMPLES OF LEADING AND NON-LEADING QUERIES

Inappropriate queries

1. Dr. Smith—Based on your documentation, this patient has anemia and was transfused two units of blood. Also, there was a 10-point drop in hematocrit following surgery. Please document “acute blood loss anemia,” as this patient clearly meets the clinical criteria for this diagnosis.

2. Dr. Jones—This patient has chronic obstructive pulmonary disease (COPD) and is on oxygen every night at home and has been on continuous oxygen since admission. Please document chronic respiratory failure.”

Appropriate queries

1. Dr. Smith—In your progress note on 6/20, you documented anemia and ordered transfusion of two units of blood. Also, according to the lab work done on xx/xx, the patient had a 10-point drop in hematocrit following surgery. Based on these indications, please document, in the discharge summary, the type of anemia you were treating.

2. Dr. Jones—This patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission. Based on these indications, please indicate whether you were treating one of the following diagnoses:

• Chronic respiratory failure
• Acute respiratory failure
• Acute on chronic respiratory failure
• Hypoxia
• Unable to determine
• Other:____________________