Determining parameters for physicians’ responses to queries should incorporate the convenience of the physician as well as the needs of the coding and CDI staff. For example, facilities which determine that query forms will be retained as a permanent part of the medical record may permit the physician to respond to the query directly on the form as long as sufficient documentation also exists in the body of the medical record.
Each facility should check with its state Quality Improvement Organization (QIO) for guidelines, too. Additional options include:
- We will accept the query as a progress note, as long as the document was signed, dated, timed, and created in the normal course of the chart (i.e., concurrently, at time of coding, or within the medical staff general rules and regulations within 30 days of discharge).
- We accept the response to the query on the actual query form, unless the query posed a leading question or introduced information not documented in the medical record. We follow the basic standards outlined in the AHIMA physician query practice brief.
- We do not accept coding summary forms (e.g., physician query forms) as documentation in the medical record when following diagnosis-related group (DRG) validation procedures. There should be an addendum in the medical record that is signed and dated by the physician.
If the program employs a physician advisor, set parameters for his or her involvement in the program to determine the level of involvement and his or her participation in closing outstanding queries. The physician advisor has the ability to speak peer to peer and ideally is perceived as an authority figure by other physicians. This influence can often mean the difference between physician acceptance and participation with CDI goals or complete rejection of the program.
Editor’s Note: This excerpt was taken from The Physician Queries Handbook by Marion Kruse, MBA, RN.
In the beginning, when placing queries for the type of heart failure or urosepsis, you may think that physicians will eventually learn the more specific documentation required and that your queries will no longer be necessary. I innocently thought that I would run reasons to query my physicians. Silly me!
Although not as frequently, I still had to ask those very same questions—hey doc, can you please specify the type of heart failure—years later. But I also found so many other opportunities for clarification as I grew in my understanding of the role and as clinical practice and coding rules changed.
I doubt I would have ever run out of questions, nor will you.
Many of the physicians I first worked with were very supportive and responded to education, queries, conversations etc., positively. Seeing my teaching reflected in their documentation was very encouraging. As with any group of students, however, there will always be the overachievers, the slow to grasp but committed learners, and those that just don’t understand why (nor do they care) clinical documentation matters to so much of the healthcare practice.
One physician (whom I very much learned to appreciate) sat down with me one day and said, “Laurie, did you know on average it takes 12 attempts to train a German shepherd to fetch but it takes 21 years to teach a doctor?”
So don’t worry about job security, because we are not training German shepherds to fetch, we’re helping physicians document the care they provide in a changing healthcare landscape. There will always be a reason to prove how valuable your assistance can be.
Q: I was told that a multiple choice query should have at least four options. Keeping in mind that there may be only one reasonable option in a multiple choice query, what would be a good fourth option for a query about hyperkalemia if the other options are:
A: There are many myths concerning compliant query practices so before automatically accepting a dictum of query parameters go back to the official sources to ensure compliance. By this I mean first reference the most recent guidance from the Association of Health Information Management Association (AHIMA) and the Association of Clinical Documentation Improvement Specialists (ACDIS). AHIMA is one of the four cooperating parties (along with CMS, American Hospital Association, and the National Center for Health Statistics) so its recommendations have additional credence should auditors or other investigators question your CDI program practices.
According to the 2013 “Guidelines for Achieving a Compliant Query Practice:”
“Multiple-choice query formats should include clinically significant and reasonable options as supported by the clinical indicators within the medical record, recognizing that there may be only one reasonable option. Multiple-choice query formats should also include additional options such as ‘clinically undetermined’ and ‘other’ that would allow the provider to add free text. Additional options such as ‘not clinically significant’ and ‘integral to’ may be included on the query form if appropriate.”
If you still feel a fourth choice is needed perhaps the choice of “not clinically significant” could be offered. But this would depend on the circumstances of the particular patient encounter.
The 2013 practice brief also provides an option for yes/no queries. However, the brief does recommend that even in yes/no queries that additional options be included, similar to those recommended for multiple-choice queries.
“The ‘yes/no’ query format should be constructed to include the additional options associated with multiple-choice queries (i.e., ‘other,’ ‘clinically undetermined,’ and ‘not clinically significant’ and ‘integral to’). Yes/no queries may not be used in circumstances where only clinical indicators of a condition are present and the condition/diagnosis has yet to be documented in the health record. Also, new diagnoses cannot be derived from a yes/no query.”
Again, refer to the practice brief for additional circumstances where yes/no queries may be warranted and read up on previous practice brief recommendations for a better understanding of how queries should be formatted.
When I started learning how to be an educator, I quickly learned the saying “seven times, seven ways.” The idea being we need to hear information repeatedly and receive it in a variety of ways before we are able to learn and incorporate that information in our daily practice.
Consider querying for clarification between renal insufficiency and renal failure, where the physician reads the query and asks you to just tell him what he should write. I would not start explaining the differences within the code set applied to these two terms or enter into a lengthy conversation about why the specificity is needed. Instead, point out the clinical indicators relevant to the patient as compared to the diagnostic criteria established for acute renal failure. Ask the physician to clarify if the kidneys are exhibiting failure or insufficiency based on the established criteria.
Stick to the facts. Keep it simple. Keep it relevant to the specific patient at the moment of conversation.
In this scenario, the physician needed a quick explanation. But let’s apply our “seven times, seven ways” theory by later following up on that interaction with an educational mailer or documentation tip via email to the physician. This second round of information could further highlight the needed differentiation and why this added level of specification is important to support issues such as extended length of stay, severity of illness, or resource consumption. Other ways to provide education include hanging posters in the physician lounges or documentation areas. I once even threatened to place fliers on a physician’s windshield!
The point is, that you may not always have the time (or the physician may not have the time) to engage in one-on-one education but you can use your physician queries as the first step in a more prolonged, detailed education campaign. We need to build upon each educational opportunity to reinforce the teaching. Repetition can be very valuable.
TBT: ACDIS/AHIMA ‘Guidelines for Achieving a Compliant Query Process’ outlines new query opportunities
Editor’s Note: In social media memes Throw-back Thursday (TBT) generally means someone has shared an old high school photo of you, something you most likely wish had been left unpublished–like your 80s bouffant or 70s bell bottoms. We thought we’d pick up on the theme and occasionally go back into the archives to highlight some salient CDI tid-bit rather than our fashion sense (or lack there-of). Today, we’ve chosen to pluck information from the April 2013 edition of CDI Journal in which the ACDIS/AHIMA joint committee published the latest compliant query guidance “Guidelines for Achieving a Compliant Query Process.” Specifically, the new practice brief offers new insight into how to compose multiple choice and “yes/no” queries in an effective and compliant manner. It also provides some additional definitions around the idea of what constitutes a “leading” query.
Guidelines for Achieving a Compliant Query Process
Although open-ended queries are preferred, multiple choice and “yes/no” queries are also acceptable under certain circumstances.
To support why a query was initiated, all queries must be accompanied by the relevant clinical indicator(s) that show why a more complete or accurate diagnosis or procedure is requested. Clinical indicators should be derived from the specific medical record under review and the unique episode of care. Clinical indicators supporting the query may include elements from the entire medical record, such as diagnostic findings and provider impressions. A query should include the clinical indicators, and should not indicate the impact on reimbursement.
A leading query is one that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or procedure. The justification (i.e., inclusion of relevant clinical indicators) for the query is more important than the query format.
Multiple-choice query formats should include clinically significant and reasonable options as supported by clinical indicators in the health record, recognizing that there may be only one reasonable option. As such, providing a new diagnosis as an option in a multiple choice list—as supported and substantiated by referenced clinical indicators from the health record—is not introducing new information. Multiple-choice query formats should also include additional options such as “clinically undetermined” and “other” that would allow the provider to add free text. Additional options such as “not clinically significant” and “integral to” may be included on the query form if appropriate.
The “yes/no” query format should be constructed to include the additional options associated with multiple choice queries (i.e., “other,” “clinically undetermined,” and “not clinically significant and integral to”). Yes/no queries may not be used in circumstances where only clinical indicators of a condition are present and the condition/diagnosis has yet to be documented in the health record. Also, new diagnoses cannot be derived from a yes/no query. In such circumstances, open-ended or multiple-choice query formats must be used. It is not considered leading to include a new diagnosis as part of a multiple-choice format when supported by clinical indicators.
Editor’s Note: Have a tough query situation your facility is dealing with? Join Cheryl Ericson, MS, RN, CCDS, CDIP, and Mark LeBlanc, RN, MBA, CCDS, on Tuesday, June 10, to review best practices and sample queries to help you ensure your program is both compliant and effective in the 90-minute audio conference “Physician Queries: Ensure Effective, Compliant, Regulatory-based Clarifications.”
One of the interesting realities of the appellate court system is the doggedness of those judges whose views fall in the minority, often resulting in dissenting opinions longer and stronger than those of the majority. We should never be afraid to consider the opinion of those with whom we may not agree. Sometimes it makes us think. Sometimes the minority opinion eventually becomes the majority opinion.
I think I’m in the minority when it comes to interpreting last year’s ACDIS/AHIMA practice brief, “Guidelines for Achieving a Compliant Query Practice.” Until the revised brief was disseminated, CDI specialists were very, very careful not to use queries to introduce new diagnoses into the record. If a patient had a low BMI, poor intake, documentation of cachexia and muscle wasting, etc., the CDI specialist could not ask the physician about a diagnosis of malnutrition, but could only present the supporting evidence and ask for an associated diagnosis. The physician could be left scratching their head, trying to intuit what words the CDI specialist was seeking. If one reads the new practice brief at face value, the CDI specialist should, conceivably, be able to ask for a diagnosis of malnutrition as part of a multiple choice query that includes “undetermined,” and “other,” even if malnutrition has never been stated anywhere in the record.
After all, the brief states, “[P]roviding a new diagnosis as an option in a multiple choice list–as supported and substantiated by referenced clinical indicators from the health record–is not introducing new information.” Doesn’t that make it okay?
Ok, here’s where I take the minority–heck, maybe the only one in all of CDI-land–view. Look at the examples of acceptable multiple choice queries cited in the brief.
One such example is a patient with chronic heart failure and an ejection fraction of 25%. Of course, it is not acceptable to query the physician as a yes/no, does the patient have chronic systolic heart failure. The acceptable multiple choice query takes the existing diagnosis of chronic heart failure and asks for greater specificity. By including a diagnosis of chronic systolic heart failure, the query is, in fact, introducing a diagnosis that has not already been stated in the record. However, it is not introducing anything completely new, but, rather, is a modification of an existing diagnosis. For a brand new diagnosis, the reader is referred to the open-ended query, where clinical indicators are given for a given condition and the physician is asked to document a new diagnosis based on those indicators. And indeed, the brief states, “Although open-ended queries are preferred, multiple choice and yes/no queries are also acceptable under certain circumstances.” [Emphasis added.]
What that means, for me in my minority opinion, is that we have to look very carefully and cautiously at those certain circumstances. We must pay extraordinarily strict attention to the language already existing in the medical record. To me, unless there is provider verbiage already within the record that modification would improve or clarify based on indicators already in the record, we should not be asking multiple choice questions or yes/no questions. Once we have a sliver of a diagnosis, then we are able to use the multiple choice query to pin down that diagnosis at its optimum and most compliant level. In my opinion, the brief is not meant to allow us to substitute our judgment regarding clinical indicators for that of the physician. It is meant to prevent us from having to play word games so that the physician isn’t struggling to guess at what we want.
I recognize this is a minority opinion, and I do bow to the will of the majority. Just consider that the practice brief may not be a license to ask anything you want as long as it’s in the form of a multiple choice question.
While strictly adhering to the “no new diagnoses in the query” dictum had once been the majority opinion, the tide has shifted, and both ACDIS and AHIMA have agreed (as demonstrated in the 2013 practice brief) that sometimes naming a diagnosis is warranted–just as long as the clinical indicators supporting it exist.
Q: Is it is okay to alter, add to, or take back a query form after the physician answers it?
A: There are two basic situations that support the need for a query. The first and most common situation is when there is evidence of an incomplete, vague, or missing diagnosis based on clinical indicators in the medical record. The other situation is when a diagnosis is documented that is not supported by clinical evidence. There is a nuance to this type of situation.
It isn’t for the CDI or coder to define the condition with particular clinical indicators nor is Coding Clinic a definitive source for clinical indicators, rather my litmus test is whether or not other providers would come to the same conclusion based on the same clinical evidence.
For example, although many providers are using American Society for Parenteral and Enteral Nutrition (ASPEN) criteria to support the diagnosis of malnutrition, it is not incorrect for a provider to make that diagnosis based on albumin levels as that was an accepted clinical indicator for years so other providers would likely come to the same conclusion based on the same evidence. Remember CDI and coders are not diagnosticians and our role is not to judge the quality of care, but to ensure that a diagnosis meets the definition of a reportable diagnosis before assigning a code (e.g., meets the definition of a principal or secondary diagnosis, is documented by a provider who is delivering direct patient care, is related to this episode of care, is not integral to another condition, etc.)
I cannot think of a situation where it would be acceptable to alter a query or remove a query once the provider addresses it. I would go one step further and suggest even if the provider does not answer the query, it would be inappropriate to alter or remove it. Although organizations are not required to keep the query as part of the legal health record, they are at a minimum, supposed to keep it as part of the business record. A query is discoverable and should be made available to auditors as requested. Verbal queries should be memoralized in the same format as written queries for the purpose of transparency.
My recommendation is to refer to the various AHIMA physician query practice briefs, which discuss standards of when to issue and how to construct a query. The latest industry standards developed in partnership with ACDIS, (Guidelines for Achieving a Compliant Query Practice) builds on the briefs and collective knowledge of government payment, compliance, and auditing practices. This 2013 document stresses that the reason for the query is as much, if not more, significant than the construction of the query.
Queries are vulnerable to scrutiny for several reasons. Below are a few examples.
- Were there sufficient clinical indicators to justify the query?
- The threshold I use for this type of query is would other providers come to the same conclusion based on the same evidence. It is important that CDI use evidence based criteria that is consistently throughout the health record when asking for a diagnosis to be added to the health record especially if that diagnosis would impact reimbursement or quality data
- Is the documentation open to interpretation?
- Would all coders reviewing the record come to the same conclusion and apply the same codes or would it be subjective? If there is too much variability among how the documentation could be translated then a query is necessary for clarification.
- Do coding guidelines require specific documentation like a cause-and-effect relationship?
- Is it clear which condition is the principal diagnosis or is it an unusual occasion where more than one diagnosis could be the principal diagnosis?
- This is a more recent phenomenon as CMS further clarifies what kinds of conditions can support an “admission” to inpatient care compared to a condition that can be treated in the outpatient/observation setting
- There are several references throughout the coding guidelines and from CMS educational tools that state if it is not clear which is the principal diagnosis the provider should be queried
Additionally, the 2013 document recommends if the provider documents on the query form itself, then it should be retained as part of the permanent health record. If the query is part of the health record then it must comply with all authentication requirements associated with the medical record. I know of no situation where a record can be altered following provider validation except by the provider when it is clearly identified as an addendum or alternation. Your CDI program/organization in consultation with the medical staff should determine whether to keep queries as a permanent part of the legal health record or not. I do recommend, though, if the coder’s query are part of the health record then the CDI queries should also be part of the health record as it would be difficult from a compliance standpoint to justify why one is part of the health record and the other is not.
However, even if the query form is not governed by authentication requirements associated with the legal health record because it is only part of the business record, it would be inappropriate to alter a document validated by another. I think it would also be an ethical issue as the integrity of the CDI and the provider could be affected by altering a document that was already addressed. The impact of a query is usually recorded as a CDI performance metric. Most CDI departments monitor queries for:
- Response rate
- Did the provider responded even if they disagreed
- Agreement rate
- Did the query result in a change in the health record
- Effect on the claim
- Did the query impact reimbursement and/or quality
Therefore, altering a query could alter CDI metrics. It could also mask CDI performance issues such as not understanding when a query is warranted as well as issues with query construction. The best course of action would probably be to “close” the query and then reissue a new query with the new and/or updated information; however, this may be frustrating to the provider if they already responded once to a similar query. A query that requires additional revision after submitting it to the provider may be a learning opportunity for the CDI constructing the query so they are able to be more precise and accurate the next time they construct a similar query.
Hope this helps!
- Use available resources. When revising query templates, refer to the ICD-10-CM/PCS manuals as well as the joint ACDIS/AHIMA 2013 query
practice brief, Guidelines for Achieving a Compliance Query Practice. As Coding Clinic begins to publish ICD-10-related questions and answers, be sure to review this information as well. ACDIS Advisory Board member Cheryl Ericson, MS, RN, CCDS, CDI-P, CDI Education Director, for HCPro, Inc., in Danvers, Mass., reviews each AHA Coding Clinic for applicable ICD-10 and CDI insight in each edition of the quarterly CDI Journal.
- Team up. It may be challenging for coders to translate some of the clinical details of ICD-10-CM/PCS into query templates without leading physicians, says Cheryl Robbins, RHIT, CCS, director of remote coding operations for Precyse in Dallas. “The query will need to be written very clearly and with more clinical detail. If it’s not done well, it could potentially be leading,” she says. Coders should work with CDI specialists and/or a physician champion when revising templates, she adds.
- Take it slowly. “Consider looking at a diagnosis or procedure a week,” says Sandra L. Macica, M.S., RHIA, CCS, coding content manager at Elsevier in Atlanta. “As coders are currently assigning codes, they can be on the lookout for problem areas. The challenge is that if that are not very familiar with ICD-10-CM/PCS, they don’t know what those problem areas are yet.”
- Plan ahead. Finding the time and resources to devote to this effort may be challenging as well, says Gloryanne Bryant, RHIA, CCS, CDIP, CCDS, HIM professional in Fremont, Calif.. “Lack of resources is usually the number one issue. Set aside time with your own staff or hire external resources to assist with this effort,” she says. “You don’t want to have massive volumes of queries being generated and sent to physicians on October 1, 2014, and through the first two or three months following go live. You want to be proactive rather than reactive, so use the coming months to get ready.”
We all have those tough days to be sure. Some days are tougher than others. But when a physician writes, “Duh! It’s a no brainer!” in response to a query you’ve just asked, it can be a little tough to take. Thankfully, CDI professionals have a committed network of their peers by way of the ACDIS CDI Talk message group to help turn such affronts into opportunities for amusement. The following are a few of the funnier responses to query efforts exchanged recently:
- On a query related to the depth and degree of excisional debridement: “I cut her in the operating room.”
- On a query regarding the type of pneumonia: “The kind that’s in the lung.”
- On a query regarding the type of pneumonia being treated with Vanco: “The patient came from a nursing home after having already been hospitalized in the past two weeks so it is obvious that is HCAP.”
- On a query for morbid obesity: “OMG, have you seen her?” and “Yes, she is a big girl!”
- On a query for morbid obesity which included the body mass index formula: “I much prefer the Ringling Brothers Circus’ way of doing this!”
- On a query for the type of congestive heart failure: “I don’t know. Ask God.”
- On a query related to the relevance of sodium treatment with intravenous fluid: “The relevance is that it gives you a job to do every day.”
The exchange prompted a revision of the following joke letter from a CDI specialist to CMS and other payers regarding use of clinically specific language:
Dear CMS, et al;
On behalf of our esteemed physician, Dr. __________________, we are making the following request:
When he says: _____________________________ He actually means:___________________________
Since it should be obvious, would you mind changing the rules that are applied when the dictation is that of Dr. Unabletodocument? He is very busy with his patients and doesn’t have time to keep learning specific word choices.
CDI Specialists of the World
Based on the 2008 AHIMA query practice guidance “Managing an Effective Query Process” many in the CDI industry believed that yes/no queries were acceptable only for those queries related to present on admission diagnosis. At times, this left CDI specialists in the awkward position of asking what may have seemed like a silly question using really poor grammar.
For example, physicians frequently neglect to cross-document findings from the surgical pathology report. For most CDI specialists, the easiest way to deal with this situation would have been to query the physician and ask whether he or she agrees with the path report. Concerned that such a yes/no question violated industry guidance, CDI specialists wrote open-ended queries such as “please clarify the clinical diagnosis associated with the stage 3 malignant ovarian cancer on the pathology report” or multiple choice queries that included limited options or findings different from the pathology report such as benign, pathology aberration, etc. In both cases, the phrasing tended to annoy physicians.
In the 2013 ACDIS/AHIMA physician query guidance the use of yes/no queries was expanded to include:
- Substantiating or further specifying a diagnosis already present (i.e., findings in pathology, radiology, and other diagnostic reports)
- Establishing a cause-and-effect relationship between documented conditions such as manifestation/etiology, complications, and conditions/diagnostic findings (i.e., hypertension and congestive heart failure, diabetes mellitus, and chronic kidney disease)
- Resolving conflicting documentation from multiple practitioners (i.e., asking the attending physician who is documenting “renal failure” if he agrees with “CKD stage 4″ documented by the renal consultant.
Based on the above guidelines, a yes/no query would never be appropriate for a new diagnosis. Moreover, to ensure a yes/no query is not leading, non-POA queries should include “other” and “clinically undetermined” options. The use of these options allows this format to meet the standard of not being leading.