verbal queries

donnakellykent@gmail.com

Up until now I was always taught that we could ask verbal queries as long as we recorded the query in the CDI software we are using AND made sure the physician documented a response in the progress notes and/or discharge summary.

Recently one of our coders said we could not do that because unless we actually placed the query in Message Center in Cerner they, coding would have no way to track it. We track in in 3M 360 and want to take full advantage of when we actually get to see physicians face to face.

Any thoughts or experience to resolve this? I have not gone back to the AHIMA query practice brief yet to see if it addresses this question.

Thanks,

Donna

katysuegood@gmail.com

per the practice brief verbal queries are fine. They should be documented in some form as to what you said in your software as you are already doing. Providers need to document their response in the record as you have stated.

I don't see any issue with what you are describing. I also don't understand how this impacts coding? as long as the provider is documenting the response in the record, there shouldn't be need for coders to track it. Unless they are responsible for some sort of followup?

morris-jeff@CooperHealth.edu

Donna,
Just reviewed the AHIMA/ACDIS Query Practice Brief today with some new employees and verbal queries are fine as long as they are "memorialized" in some way. I'd suggest you put them in 360 and type them just as you would a query you'd issue to the Provider. 

jackietouch@aol.com

Most of my queries are done verbally with the providers during team rounds. I enter them in our CDI software (we use Nuance/JATA CDMP embedded in Cerner) just as we do electronic queries and make sure that the MD documents in the progress note and/or diagnosis list. I then indicate the provider's response on my verbal query form with rationale.  Our coders have access to view our queries if they have any questions while coding.

Amy_Stremming_1992

We only have a couple of CDI staff who go to rounds and initiate verbal queries; the remainder of our queries are electronic as we do not work onsite at the hospital (space issues). We were taught to enter verbal queries in 3M HDM just as we would enter written queries. Once the provider documents a response, the coder can code the diagnoses that are documented. That should be all they need unless they want to see what you asked (which as noted above, they could view them in your software). As far as I know, there is no need for the coders to 'track' our queries?

donnakellykent@gmail.com

Thank you all for the support of how we are handling this. Sounds like we're on the same page.

sbuchanan@svhs.org

We have always done verbal queries as described above.  Recently we have changed our policy to state that all concurrent queries will become a permanent part of the medical record.  A request has been received that when a physician gives a verbal response over the phone that we document his response on  the query form for him to date, time and sign the next time he makes rounds.  I have been asked to consider this but I have many concerns.  May I have your comments please?