August 12, 2015 | | Comments 0
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Q&A: Query rate metrics

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Q: I noticed that several programs do not seem to have a query percentage rate that they must meet. My facility has a goal of 35%, which was set by a consulting company about five years ago when our program was started. Is there a more realistic query rate percentage we should aim for? What do other programs set as a goal?

A: There are several concerns with having a set query rate. Query opportunities vary through the “life” of CDI efforts. Initially, there may be a high query rate (i.e., type of heart failure with CHF), but once physicians become educated—which should be the goal of CDI efforts—those “clarification” queries should decrease in volume.

As a CDI department matures, the type of queries often become more sophisticated, moving from queries that clarify an existing diagnosis to identifying missing diagnoses and/or clinical validation of documented diagnoses, which may be less prevalent.

A continued high query rate among seasoned CDI specialists could actually be seen as a potential performance issue, because it could indicate the CDI specialists is not effective in establishing relationships with providers and delivering education. The goal of CDI is to reduce the query rate over time, as improved documentation practices become ingrained in the culture of the organization.

Query rates also vary across service lines. Those reviewing orthopedic cases are not likely to have as many opportunities for queries as those reviewing cardiac cases. If everyone doesn’t have the same opportunity to issue queries, then it seems unfair to use this as a performance metric. If it is a departmental metric, those with query opportunities would have to be above 35% to offset those with limited query opportunities.

Both ACDIS and AHIIMA provide in their guidance that querying should not be a “fishing” expedition. If organizations require a 35% query rate, it might incentivize inappropriate queries. So, for example, a CDI specialist might leave extra pneumonia or sepsis queries without relevant clinical indicators just to meet their query rate goals.

As a manager, you’d then  need to consider the effect of that inappropriate query on provider perception of CDI efforts. CDI staff could lose credibility with the medical staff. Remember “the justification (i.e., inclusion of relevant clinical indicators) for the query is more important than the query format,” according to the 2013 ACDIS/AHIMA query practice brief.

Inappropriate queries could also bring about the potential for query fatigue. When you ask physicians too many queries, they often stop responding. This same issue happens with excessive alerts in electronic health records.

Organizations need to have a query policy that helps them prioritize their query efforts. This is particularly important with ICD-10-CM/PCS implementation. Both CDI and coding need their own query policies, because each department has its own mission. As such, the extent of querying by CDI will depend on their mission:

  1. MS-DRG validation: If a CDI department reviews records for DRG validation under MS-DRG reimbursement, then they only need to “validate” those diagnosis that affect reimbursement, such as the principal diagnosis and CC/MCCs.
  2. APR-DRG validation: If the organization reviews Medicaid patients paid under APR-DRG, then the DRG validation process is more complex. Any diagnosis can potentially affect reimbursement, so all diagnoses need to be reported to their highest specificity, which can result in more queries.
  3. Quality: If the CDI department is querying for “quality,” then they need to know what impacts “quality.” This can include mortality, U.S. News and World Report rankings, CMS quality measures, patient safety indicators (PSIs), etc.

The days of one-size-fits-all is long-gone in the world of CDI, as a CDI department can affect many processes associated with coded data. The mission of CDI should fit the needs of the organization, which can evolve over time. The CDI department should be a separate, but complementary function to the coding department—n ot just its “query arm.” .

Knowing the mission of the CDI department can help determine appropriate measures for success. A query rate isn’t an effective metric through the “life” of a CDI department. However, if a facility does keep a query rate metric, there should also be a quality or audit process in place that monitors the quality of the queries and their compliance with professional standards of practice.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc. and Associate Director of ACDIS for Education, answered this question. Contact her at cericson@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview.

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Katherine Rushlau About the Author: Katherine "Katy" Rushlau is the CDI Editor for ACDIS at HCPro.

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