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Book excerpt: Peer review to ensure compliant query practices

Start your weekend with some CDI reading!

Start your weekend with some CDI reading!

By Marion Kruse, BSN, RN, MBA, and Jennifer Cavagnac, CCDS

Every CDI program should objectively evaluate the outcomes, processes, and compliance of their CDI efforts. Auditing and monitoring provides oversight for the CDI program, insight into physician documentation and collaboration, and objective evaluation of the performance and effectiveness of individual CDI staff members as measured against your facility’s policies and priorities.

According to AHIMA’s “Managing an Effective Query Process” “Healthcare entities should consider establishing an auditing and monitoring program as a means to improve their query processes.” [more]

Q&A: Receiving query responses from providers

Have CDI questions?

Have CDI questions?

Q: Our hospital is having a hard time getting our physicians to respond to queries, do you have any suggestions on how to get them to reply?

A: The most important thing is make sure the query is concise and contains clinical indicators from the record. You also want to use different methods of contacting the physician as well. Various points of contact include within the electronic health record, via e-mail, by phone, or by having your CDI team visit them on the floor. [more]

Q&A: Electronic query formatting

Have CDI questions?

Have CDI questions?

Q: We use an electronic system at our hospital, and find it is difficult to query a physician since we all have our own processes. Would you recommend having a set format for a query that is used electronically?

A: This is going to be contingent on the system your facility uses.

Some EHRs have pretty complex platforms that will allow you to build templates and write a narrative. Here you would write your question, provide all of the appropriate details, and there would be a more formatted, outlined section below where the individual leaving the query can populate the form within that template.


Q&A: Missing documentation for acute kidney injury


Ask ACDIS all your CDI questions!

Q: We are currently coding a chart for an acute kidney injury which has the baseline serum creatinine and urine output missing from the chart. Is there something we can do to identify additional information before we have to query the physician?


Tip: Advance CDI’s cause through technology

CDI and technology

Technology changes the way CDI operates every day.

Those who’ve been in CDI long enough remember the days of colored paper queries slipped into charts. Often, those queries would get lost in the literal shuffle, or simply go unanswered and ignored with no concrete way of tracking the query.

Then, electronic health records (EHR) came on the scene, changing the CDI process for nearly everyone.

“Simply put, the advent of EHRs and e-queries changed how CDI specialists work—and the days of misplaced paper queries and incoherent penmanship are all but gone,” according to a special report out from ACDIS and HealthLeaders Media, in partnership with Optum360, “Leveraging technology to advance CDI efforts.”

Like all changes, EHR comes with rewards and challenges. CDI programs gain the flexibility and supportive data to meet the needs of the healthcare systems they serve. All while increasing productivity.

“With any new system, issues are going to have to be addressed,” Kathy McDiarmid, RN, CDI specialist at Beverly Hospital, a member of the Lahey Health System in Massachusetts, told the CDI Journal in December.

“There will be little things that physicians forget,” she says. Yet armed with intimate knowledge of the programs chosen, CDI staff can help physicians navigate the EHR and provide real-time assistance once the programs are in use, says Colleen Stukenberg, RN, MSN, CMSRN, CCDS, director of resource management at FHN in Freeport, Illinois, in a 2016 CDI Week Q&A for ACDIS.

In order to fully leverage the new technology, according to the report, CDI specialists need to understand the technology first. This knowledge gives them another platform from which to reach out to physicians. The CDI team can be a resource and help ease the transition to a new system for the physician.

To learn more about leveraging your EHR system to improve physician engagement and productivity, read the entire report by clicking here.

Guest post: Querying for clinical validity

by Erica E. Remer, MD, FACEP, CCDS

Some clinicians may interpret a query as an affront to their clinical judgment. This is not your intent. You are trying to determine whether a condition was present and whether it should compliantly be coded or not.

Here is an example of how a coder would provide the clinical indicators in the affirmative for the clinician to answer the query in regards to an intimated diagnosis:

Dear Dr. So and So,

The SCr was 3.4 and two days ago it was 1.4. You documented “renal dysfunction likely due to contrast.” Is there a diagnosis that corresponds to this?

You can also provide the physician with the documented diagnosis and the clinical indicators which make you skeptical:

Dear Dr. So and So,

You documented that this patient had pneumonia in the history and physical assessment. Over the course of the next three days, the repeat chest x-rays were read by the radiologists as “no infiltrate,” the sputum and blood cultures did not grow any organism out, and antibiotics were discontinued. However, the impression list continues to list “pneumonia.” Based on this information, please confirm the patient’s condition and your medical decision making, clinical support for the diagnosis in the medical record. If pneumonia was ruled out, please amend the assessment and plan, diagnosis list.

If a physician advisor supports the coding and CDI departments involve him or her in the process. The physician advisor can help create internal clinical guidelines to help providers ward off CVDs by standardizing criteria.

Make sure your providers see coders and CDI professionals as an ally, not an adversary, and that goal of CDI efforts is to protect both the physician and the facility from unnecessary denials.

Become educated

The last step is education—both for the CDI staff and for the physician.

Physicians often don’t know about clinical validations denials. When they occur, share them with providers. Point out what could have prevented them. Reinforce the good habit of documenting their thought process and explaining why they are doing what they are doing to and for the patient. Don’t accept responses to queries with only diagnoses and no clinical evidence supporting them.

Educate CDI and coding teams. If you have regular staff meetings, you can discuss topics which seem to be eliciting clinical validation denials. Changing clinical criteria may herald impending denials. Crowdsource best approaches to specific clinicians and specific conditions. Have joint discussions between coders and the CDI staff.

Clinical validation denials require time, energy, and resources to revisit patient encounters coded in the past. Concurrent clinical validation practices can prevent future denials by shoring up clinical support of valid diagnoses and eliminating others. An ounce of prevention is worth a pound of cure.

Editor’s note: This article, written by Erica E. Remer, MD, FACEP, CCDS, founder and president of Erica Remer, MD, Inc., Consulting Services, first appeared in its entirety, in JustCoding. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Contact her at



ICD-10 Tip of the Week: Have a plan in place for queries

Take a look at your emergency room records to ensure that E/M efforts are appropriately captured

Do yourself a favor: plan out an updated ICD-10 query process and policy now.

The ICD-10 code set is complex. The volume of codes and required increased documentation specificity alone is enough to overwhelm even the most sophisticated CDI programs. Do yourself a favor: plan out an updated query process and policy now.

The number of queries associated with a given health record will likely increase post-ICD-10 implementation. If you haven’t already, start educating CDI and coding staff on documentation needs associated with the new code set, and prevent future documentation woes before they occur. Likewise, programs should begin including ICD-10-CM/PCS elements in targeted queries for high-volume diagnoses, specific to your facility. Practice documenting and querying for ICD-10 now, and CDI, coders, and physicians alike will be better prepared.

CDI departments also need to review their query policies [more]

Q&A: What to do with unanswered queries

You've got questions? Let us know!

You’ve got questions? Let us know!

Q: In my facility, we are supposed to send an e-mail to our physician advisor (PA) and to administration if a query is not answered within a week. However, this policy doesn’t work well because administration does not do anything with that information, and the PA doesn’t have time to review unanswered queries. Do you have any suggestions concerning when to let a query go unanswered?

A: We do suggest every CDI program have well-developed query policies. These should be consistent with those policies followed by the coding department. Look at how unanswered queries are addressed on the retrospective side.

Your query policies should include clear guidance on what instances queries are to be asked, where they are placed within the record, and who is responsible for follow-through. You should also have guidance on how queries are to be prioritized.

Query policies should also include an escalation policy that describes how to handle situations in which an answer is not received, an inappropriate answer or comment is provided, etc. The escalation policy should address when the issue is brought to the physician advisor, your department director, or administration with defined actions as to the responsibilities at each level. The policies should reflect a method of response that can realistically occur for your organization.

In my experience, if a query was unanswered, the CDI specialist and inpatient coder would discuss the need for follow up. If it was determined that the answer would provide little impact, we would close it, leaving the query unanswered. But if we concluded an answer was required, the CDI specialist would address with the provider. There was a process of escalation in those instances when no response was received.

Ultimately, your policies should indicate what instances a query can go unanswered, and when it should be followed through. There may be instances when a query does not impact the reimbursement or quality measures and can be left unanswered. These are conversations that must be discussed within your organization.

Few organizations can boast a query response rate of 100%, but there are some things you can do to boost response rates. Take a look at your query templates or perform a query audit. There should always be choices that allow the physician to offer his or her own interpretation, or to state that there is no significance or the answer is unknown. Often, physicians do not answer queries because they either do not like the choices offered or they are unsure exactly what is being asked.

It might be helpful to monitor physician query response rate based on the CDI specialist responsible for the account. You may find a specific CDI specialist is having difficulty writing effective queries or lacks assertiveness in follow-up on unanswered queries. Most programs have a set time limit or goal for queries to be answered that is tied to individual CDI productivity or effectiveness in the role. For example, an expectation that 80% of all queries asked will be answered within 48 hours.

Administrative support is invaluable in encouraging physician involvement in your program. Many organizations track physician response rates to queries in their physician profiling, or “quality report card” efforts. Instead of forwarding administration every unanswered query, set an acceptable response rate. When a physician falls below the suggested benchmark, the matter should be addressed by a department director, PA, or senior administration.

I also like to give positive reinforcement where it is due. Recognize those physicians who are working with you and are demonstrating a high response rate. It creates a sense of competition and, often, we catch more flies with honey.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at For information regarding CDI Boot Camps visit The next Boot Camp will be held April 27–30, 2015, in Washington, D.C.

Last Week on CDI Talk: Assigning queries to residents

How do you assign queries to residents, PAs, and NPs?

How do you assign queries to residents, PAs, and NPs?

Editor’s Note: CDI Talk is a networking forum for ACDIS members, in which members ask pressing questions and garner the opinion and expertise of their peers. Join by clicking on the CDI Talk tab on the ACDIS website.

Academic medical centers face a whole different set of challenges when it comes to CDI. In one recent discussion on CDI Talk, users discussed how academic medical centers assign queries, specifically if they should address the query to the treating resident or the attending physician. Users also debated whether or not they should require a co-signature for resident’s answers from the attending, and if the same policies apply to nurse practitioners (NPs) and physician assistants (PAs).

Query processes should be outlined in hospital by-laws, says Angelisa Romanello, RN, BSN, FNS, CCDS, CDI Manager at the CJW Medical Center in Richmond, Virginia. For example, per her facility’s by-laws, CDI specialists only query residents, NPs, and PAs who work for their hospitalist group. For any the service line, the attending has to be queried. This helps hold the attending responsible for their students, she says.

Clinicians are licensed to “establish a diagnosis independently,” Sutter West Bay in San Francisco, California doesn’t require a countersignature for NPs and PAs, says Paul Evans, RHIA, CCS, CCS-P, CCDS, manager of the CDI program there.  Residents, however, are required to have any and all notes, including a query response, counter-signed by the attending, as per their hospital’s by-laws.

“If a resident is working with an attending, we send the query to the attending,” says Evans. “Often, the attending will expect the resident to answer our query, and that query must then be signed by the attending.”

State laws are important to consider when speaking to the responsibility of the attending physicians in terms of resident oversight and medical records, according to Robert Billerbeck, MC, CPC, owner of Meditco LLC in Colorado. Colorado law considers NPs a “Licensed Independent Practitioner” (LIP) for primary care, and therefore require no co-signature. However, the state law does require a PA to obtain a co-signature and other oversight. Facilities, he says, may have their own rules that meet state regulations, but some facilities’ in-house rules go further than others. For example, a facility can require an MD co-signature for NPs, even though the state does not require it, and other facilities may not have the same requirement. And rules differ from state to state.

“The bottom line is we need to know both state and facility rules when determining signature requirements for any given location,” says Billerbeck.

Residents are often more open to CDI efforts than seasoned physicians, says Deborah Dallen, RN, CCDS, CDI Supervisor at Einstein Medical Center in Philadelphia, Pennsylvania. Her team queries residents, PAs, and NPs on any service. Queries are usually assigned to the primary team with the exception of debridement and OR report clarifications, which are usually assigned to the surgical resident or attending physician. Dallen and her staff have an excellent response rate with residents and, despite the required 24-hour turnaround requirement, they usually meet their deadlines both concurrently and post-discharge.

Queries are not always formally mentioned in hospital bylaws, however, says Katy Good, RN, BSN, CCDS, CCS, CDI Program Coordinator, and AHIMA Approved ICD-10CM/PCS Trainer at Flagstaff Medical Center in Arizona. Many facilities treat queries like progress notes, and maintain them as a permanent part of the medical record. The guidelines for progress notes indicate who can independently sign a progress note. If query guidelines are not explicitly outlined in a facility’s by-laws, the guidelines for progress notes can be used when figuring out who can sign queries.

For example, at Good’s facility, by following the guidelines for progress notes and applying them to queries, residents require a co-signature. Further, queries are sent to the attending, and they are responsible for assigning the query to the resident. Similarly, PAs require a co-signature for progress notes at her facility, and therefore CDI specialists do not send queries directly to them. NPs do not require a signature for progress notes, so CDI specialists do send queries directly to them. Check with physician groups about their preferences for handling queries—some who employ NPs will want the queries sent directly to the NP, rather than the surgeons or physicians themselves.

Guidance on documentation requests, queries, and late entries in the record

Lynne Spryszak, HCPro’s CDI Education Director, was one of several speakers offering great information during yesterday’s ACDIS members’ Quarterly Conference Call. She mentioned a November 2011 CMS publication about documentation requests that can have a direct impact on provider requests. Here is the link:

Lynne also provided more information from the Medicare Benefit Manual: – Late Entries in Medical Documentation

(Rev. 377, Issued: 05-27-11, Effective: 06-28-11, Implementation: 06-28-11) This section applies MACs, CERT, Recovery Auditors, and ZPICs, as indicated.

“A provider may discover that certain documents were misfiled or needed to be filed in the medical documentation during the process of responding to an ADR. Providers are encouraged to add to the medical record or notes file all relevant documents that were created at the time of service or within a few days of the date of service.

“The MACs, CERT, Recovery Auditors, and ZPICs shall give less weight when making review determinations to documentation, including a provider’s internal query responses, created more than 30 calendar days following the date of service. If the MACs, CERT, or Recovery Auditors identify providers with patterns of making late (more than 30 calendar days past the date of service) entries in the medical documentation, including the query responses, the reviewers shall refer the cases to ZPIC and may consider referring to the RO and State Agency.”

Thank you, Lynne!