All Entries Tagged With: "policies and procedures"
To lead or not to lead: Forming compliant queries
“Whether tis nobler in the mind to suffer
the sling of outrageous fortune,
or to take arms against a sea of troubles,
and by opposing, end them.”
~Hamlet, Act III, Scene I
Shakespear as CDI? Hummm. . .
I truly think that Shakespeare was a frustrated CDI nurse.
I was not fortunate enough to attend the annual ACDIS convention in Las Vegas, but my colleagues let me read through their books. The AHIMA practice brief baffled me when it was introduced in 2008. Has anyone read this carefully? There is an interesting quote from a CMS memorandum issued on October 11, 2001:
“CMS Position is that a query form should not be leading, and it should not introduce new information not otherwise contained in the medical record.”
If a physician documents that a patient has hemoglobin of 5, how can anyone query for anemia if use of the word anemia is prohibited? Furthermore, query forms should not have the name of the condition, diagnosis, or procedure unless such was already listed in the medical record.
Any nurse who works in a hospital intensive care unit has seen the vent setting carefully listed on the record with no mention of the patient being intubated or why. How can a CDI clarify acute respiratory failure and the intubation procedure without mention of the vent, the endotracheal tube or the possible causative diagnosis?
I can understand phrasing the query in a question format (after all I grew up watching Jeopardy): “What is the underlying diagnosis?” I can also understand the rationale for not phrasing the question in a “Yes” or “No” manner. I would not want a physician to say “yes” and then not document anything on the progress note. This is self explanatory. What I have a hard time understanding is what appears to be the systematic torture of physicians who are exposed to ambiguous clarification forms.
Establish a policy to address query form use
Whether your facility handles physician queries specifically within a dedicated CDI program or within your HIM department be sure to get advice from your team of physicians when developing a query policy. With a draft in hand, have your hospital’s HIM and compliance department committees review and approve the policy. And don’t forget to consult the September 2008 AHIMA physician query practice brief “Managing an effective query process.”
Make sure your draft query form is clear and concise, presents facts from the medical record and identifies the need for clarification based on clinical indications, provides open-ended questions rather than multiple-choice or “yes” or “no” responses. Such specifications help reduce the risk that your query will lead the physician to document a diagnosis that was not clinically accurate.
Your organization’s policy should eliminate the use of general queries. For example, do not make it a policy to query any/all cases without a documented secondary condition. Instead, formulate a policy that allows the facility to query physicians based on indications (or lack thereof) specific to the patient’s treatment.
Editor’s note: This post was adapted from the book Coder Productivity: Tapping your Team’s Talents to Improve Quality and Reduce Accounts Receivable. For information, call 877/727-1728.
ACDIS members have access to sample physician query policies and procedures in the Forms & Tools Library on the ACDIS Web site.
Tip: Adapt policies and procedures for physician queries
One policy fits all.
When AHIMA released its “Managing an Effective Query Process” brief in September 2008, it raised a number of concerns among them the responsibility of a CDI program to draft consistent policies and procedures for conducting physician queries. In a recent ACDIS poll, 29% of respondents said they did not have a query policy in place and 43% said their facility allows CDI staff a “flexible” query system.
Be careful about developing multiple rules for your facility query process, says Garri Garrison, RN, CPUR, CPC, CMC, director of consulting services for 3M Health Information Services in Atlanta. The Department of Justice and the Office of the Inspector General “don’t care who asked the question”—either the HIM professionals in the coding department or a registered nurse in the CDI program—if the query leads the physician to document in an inappropriate way. So make sure when you develop your policy that you establish one approach and that everyone involved in the CDI program—coder, nurse, physician advisor—follows that approach.
Hear what Gloryanne Bryant, RHIA, CCS, senior director corporate coding HIM compliance department at Catholic Healthcare West in San Francisco had to say during the ACDIS quarterly conference call:
The quarterly conference calls allows ACDIS members to speak with each other and industry experts as an informal networking opportunity. Those who are unable to listen to the call “live” may access the MP3 recording of the call on the ACDIS Web site.
ACDIS has a number of sample policies and procedures available in the Forms & Tools section of the Web site. Download a sample inpatient physician query policy that you can adapt to your facility’s needs.
Compliance eyes CDI concerns
When brought to court under a False Claims Act whistleblower suit, a miscommunication regarding leading physician queries no longer seems like a misdemeanor. One potential suit is rumored (it has not been publicly released yet) to have its roots in CDI, according to a January 26 article in the Report on Medicare Compliance.
The article outlines a few emerging compliance concerns and quotes our own ACDIS board member Robert Gold, MD, who reiterated for the compliance crowd that the goal of a CDI program is improved documentation.
Furthermore, the goal of improved documentation should be consistent across payers and disease-type, he says. The goal shouldn’t be improved documentation-but only for Medicare patients. It shouldn’t be improved documentation-only for acute respiratory failure patients. Or only for any other special situation. Where consistency lags, the risk for fraud excels.
In CDI Strategies on January 22, we explored a few ways you can work with your compliance officer to locate risk areas and develop compliance policies and procedures. A first step, of course, is to reach out to your facility’s compliance officer and tell him or her about your CDI program. If you do not have a compliance program at your facility, consider reaching out to other facilities in your area. Ask an experienced compliance professional to help you scrutinize your program’s practices, policies, and procedures to ensure you don’t run afoul of the law.
Look for additional tips and the latest information in the upcoming quarterly CDI Journal. In the meantime, please let us know if you are currently working with your compliance officer and what tools or tips you might have developed that you wouldn’t mind sharing with others.
New England Regional CDS meeting set
The New England Regional Clinical Documentation Specialists meeting is slated for Thursday, 
February 26, 1:15-3:30 p.m. at Norwood Hospital, in Norwood, MA. Plans include discussions with an infectious disease physician regarding sepsis and, time permitting, additional discussion regarding CDI policies and procedures.
Check out the following documents that Bernadine Darienzzo sent over:
Have any of you been struggling with forming policies and procedures for your departments? We’ve been hearing some questions and concerns from various corners. Please let me know what you’re focusing on in this area by posting a comment. I could really use your help developing an article or focus group! And it might help generate conversation for our New England friends.