February 23, 2016 | | Comments 0
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Ask ACDIS: Creating Compliant Verbal Query Processes

Seems there's no end to questions about the difference between SIRS and sepsis. Here's a brief reminder from Dr. Gold.

Not all verbal interactions between the physician and the CDI specialist rise to the level of a verbal query.

Q: Can you clarify the expectations related to documenting the discussion between a physician and a CDI specialist when a query is done verbally. The 2013 ACDIS/AHIMA physician query practice brief Guidelines for Achieving a Compliant Query Practice expanded on the need to document this interaction and we’re wondering if our process is compliant.

We write out the query form and discuss it with the physician. If the physician agrees, he or she adds the detail into the medical record. On the completed form, we simply add a “V” or the words “verbal query.”

Do you have any additional advice? How do you recommend programs track verbal queries for compliance?

A: Not all verbal interactions between the physician and the CDI specialist rise to the level of a verbal query, says ACDIS Advisory Board member Anny P. Yuen, RHIA, CCS, CCDS, CDIP, director of ambulatory CDI at Enjoin. All CDI programs need to establish policies and procedures surrounding verbal queries and how they are tracked. All organizations should have a permanent record of verbal query language in order to demonstrate compliance and allow for adequate quality monitoring.

Such policies should follow guidance from ACDIS/AHIMA, agrees ACDIS Advisory Board member Judy Schade, RN, MSN, CCM, CCDS, CDI specialist at the Mayo Clinic Hospital in Arizona, who offers the following tips:

  1. Determine if the verbal discussion was educational or related to a documentation opportunity.
    1. If the CDI specialist presents the physician with specific clinical indicators, diagnostic results, interventions, and treatment plan related to a particular patient with an expected outcome then it is a verbal query.
    2. If the discussion relates to general documentation tips regarding a diagnosis or disease process, it’s likely educational in nature.
  2. Verbal queries need to follow the same compliance standards as written queries, so the CDI specialist needs to document that query and ensure there was no mention of a diagnosis, and the intent of the query (e.g., if the query was to clarify conflicting documentation in the record). CDI staff also needs to include the applicable:
    1. clinical indicators
    2. treatments
    3. diagnostic results
    4. progress notes
    5. nursing notes
    6. possible diagnosis options along with other or unable to determine
  3. Monitor and trend verbal queries for educational and quality purposes just as with written queries. “These can be used in outcome assessments so it’s very important that verbal queries are documented and reviewed,” Schade says.

The important focus is that all queries should follow the same policy/procedure/process and are not leading or offering the diagnosis, she says.

At a minimum, says Yuen, programs should track:

  • Name of the CDI specialist conducting the query
  • Name of the physician being queried
  • Subject of the query
  • Date, time, and location of the verbal query
  • Result (i.e., agree, disagree, other)

“Always encourage adherence to the practice brief guidelines regarding documentation of verbal queries,” says ACDIS Advisory Board member Wendy Clesi, RN, CCDS, CDIP, director of CDI services, Enjoin. “Verbal queries should be delivered in the same fashion as a written query (non-leading) including clinical indicators and treatments specific to the individual case (if using menu options, only offer clinically viable options specific to the scenario being presented), and the documentation of the occurrence for record keeping purposes should recount the conversation to ensure compliance with the query process. In regards to the specific scenario presented, it is always good practice to follow up a verbal query with a written or vice versa.”

If the verbal query is presented along with a completed written query, updating the response on the form itself should be sufficient for documentation purposes.

Tracking and query retention can be managed either manually and/or electronically. This will depend on the individual facilities resources.

Editor’s Note: ACDIS Advisory Board members offered the above responses as additional information following the November 2015 ACDIS Membership Quarterly Conference Call. Listen to a recording of the call or read additional questions and answers in the January/February edition of the CDI Journal.

Entry Information

Filed Under: Questions from the MailboxTip Tuesday

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

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