Queries

sillygirl22

Does anyone use queries that utilize check boxes for their physicians,
and these queries remain in the chart? Has this helped your compliance?
If so, can you please forward a copy of one?

We write out our queries now, but would like to have better physician
compliance.



Karen Beal, RN, BSN, CCRN

Clinical Documentation Improvement Specialist

Huntington Hospital

100 W. California Blvd.

Pasadena, CA 91109

626-397-2024

Fax 626-397-2904

karen.beal@huntingtonhospital.com

sbeatty

I believe that Community Hospital of Indianapolis-South campus may use one. We have a CV surgeon who brought one to me as an example of a query he would address.
We currently write a brief statement requesting the MD to review the diagnostic criteria we've found in the chart and the corresponding ordered treatment. We ask them to document the diagnosis being treated with as much specificity as possible. Our queries have a table with findings and treatments from the literature that correspond to the diagnosis we suspect may be present or that is noted without the specificity needed. We have taken these queries to the Medical Staff Quality Management committee, which consists of all section chiefs, the CMO, the CNO and the medical director of quality, and had the content and query approved. I hope this helps.

Unknown

The only queries we use that have check boxes are the POA and the CHF. The others are written out. I did have a insurance company challenge me on the CHF to no avail.




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Logansport Memorial Hospital
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574.753.1478 (Phone)
Fax: 574.753.1515 (Fax)
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dbutler

I would suggest that to discard the query answer (which was very clearly stated by the primary physician as NO) would be unethical.

However, would consider seeking a brief conversation / meeting with the attending, pointing out the existing documentation (especially in the body of the summary) and asking him to provide an addendum to the record to provide the needed clarity. Either he will write the addendum essentially expressing that he disagrees with the Asp PNA, or will reconsider and strengthen that documentation.

Don

dvitalone1

Thanks!

DAWN M. VITALONE, RN
Clinical Documentation Improvement Specialist
Community Hospital
Munster, IN 46321
(219) 513-2611

NormaB

I'm curious as to why the coder questioned the documentation because it was in the body of the DS?

Almost sounds like you need to have a "sit-down" with the physician and explain the case from the beginning. Show him how he contradicted his original documentation with his answer to the query. (Or maybe he changed his mind?)

Maybe he doesn't mean aspiration in the way we "think" of aspiration? Therefore he was gun-shy when the Dx was queried?

Has it been the same physician both times?

dvitalone1

NO, 2 DIFFERENT MDs

DAWN M. VITALONE, RN
Clinical Documentation Improvement Specialist
Community Hospital
Munster, IN 46321
(219) 513-2611

dbutler

Agree on the sit-down, but with the coder......if it was documented clearly in the body of the DCS, there was no need I am aware of to query the attending anyway.

Other thoughts on this?

Don

NormaB

I agree with you Don. W/O seeing the actual documentation I would have coded the aspiration.

But perhaps it was worded in a way that had her question the validity of the dx. *shrugs*

dallend@einstein.edu

-
I have a couple of thoughts on this:
1. If ? asp pna was documented - we would not accept that as possible - the MD would have to document the word possible.
2. If ID was consulting and documented the pna and the attending did not disagree there is no issue. I usually query just to cover myself and ensure MD agrees with consultant.
3. Since the MD did document it in the body of the discharge summary - I don't understand why the coder queried the MD. But now that the query was done - you cannot toss it - that is unethical. I would try to meet with the attending with the discharge summary in hand. He may have been annoyed by the coder query (who knows). Perhaps you will have better luck with a 1:1 discussion.

cynthia.a.goewey

We currently do not use forms and we write our queries at the time we send them. We send our queries electronically to a tasklist in the medical record. They are not a permanent part of the medical record. If the physician does not place the requested diagnosis in the progress notes or DC summary we do not code the diagnosis...so if they respond back to us with their response and do not place it in the record we do not code it.
Cindy

Cindy Goewey RN, BSN
Clinical Documentation Specialist
Coding Operations
Dartmouth-Hitchcock Medical Center

Unknown

We have 20 standardized queries, one being a general which can be adapted to any scenario that does not fall into the standard queries.


Charlene Thiry RN, BSN, CPC, CCDS
Clinical Documentation Specialist
Quality Resources
Menorah Medical Center
5721 W. 119th Street | Overland Park, Kansas 66209
Charlene.Thiry@hcahealthcare.com
Mobile: 913-498-6388
www.menorahmedicalcenter.com

robert.hodges2

I have 21 that I use that are forms, but will probably have around 26 available to me in the near future. My queries also are not part of the medical record and forms are only used when the query goes through distribution to the provider. Otherwise the format of the form is followed and queries are done verbally or via email depending on provider preference.

Robert

Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
 
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
 
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens

dvitalone1

BUT, ARE THEY PART OF THE PERMENENT RECORD?

dvitalone1

I am interested in your general query. Would you be willing to share it?

ggoodman@virginiahospitalcenter.com

We do not use pre-typed query forms for CHF, AKI, etc. We have pink
forms that we leave in the chart that have a blank space for us to write
out our query. Our clarifications are not part of the permanent record
and the physician must document their response in a progress note,
consultation or discharge summary.

I would be interested to see what the most common queries you all leave
are.
At out facility our top few are...
CHF, AKI/CKD stage, Respiratory Failure, Acute Blood Loss Anemia,
Malnutrition, Encephalopathy, etc.


Greta Goodman

Clinical Documentation Improvement Specialist
Clinical Documentation Improvement Program
Virginia Hospital Center

catladyrn

I have never worked in an environment where CDS queries were part of the permanent record. As nurses tend to use a little more leeway in how they phrase their queries than coders do, TPTB/Risk Management is too terrified of having potentially leading queries open for review to allow CDS queries to remain in the record.

I do have multiple templates that I am always updating and adding to, on a variety of topics. Whenever possible or appropriate, I like to include a small piece of educational material in the query form, to help them understand the rationale for the query. This is particularly important here where we are 100% EMR and have minimal face-to-face interaction with the physicians.

Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center

NormaB

We have 23 queries for use by CDI and coding staff. When used currently by the CDI Staff they are not a permanent part of the chart. If used bythe coding staff they then become permanent.

Our queries are Word Documents and may be altered for more patient specific or physician specific questions or comments.

We also have a general query for anything else wich may not be covered under our other queries.

At any time the CDS may come up with a query on their own as long as it complies with guidelines.

NBrunson, RHIA, CCDS
Bay Medical Center

mary.a.dunn

We have 12 queries that are permanent parts of the medical record. Our HIM department wants them as permanent so that they can be seen on the electronic record. It gives some credibility that the physician was asked to clarify and did answer. They feel this will help in a RAC audit. I am not used to a permanent query but I find I like it so much better. The important thing to remember is to give multiple choices, not just the ones you want or that might be leading.

dvitalone1

We use Midas and here are our queries:
Chf, chest pain, altered mental status, anemia, pneumonia, renal failure, malnutrition, uti, sepsis, cva, present on admission clarification, excision debridement, resp failure




____________________________________

Unknown

I agree 100%. With the changing world and ever changing coding system, the
development of RAC and other insurance auditing entities whose sole focus
is reduction of reimbursement to the hospitals, it is vitally important that
the physician understand the importance of his documentation. As many of
our physicians say, "it is a word game". They use this when they do not
understand why their documentation does not indicate the condition their
treatment plan clearly indicates. However, if we educate and re-educate-- not
just on those diagnoses that are CC's or MCC's or will move the DRG to a
higher DRG--but for documentation of all diagnoses-- the physicians will
understand. With ICD-10, documentation becomes even more important for the
physician.

I also see the role of CDI's more in line with educating and making sure
the documentation is there, in the beginning, throughout the chart and at the
end in the discharge summary.




In a message dated 4/17/2011 7:32:41 P.M. Eastern Daylight Time,
cdi_talk@hcprotalk.com writes:

There is certainly some excellent discussion here on appropriate
non-leading queries of late on the list-serve. One area that is missing in this
discussion is the focus upon educating the physician on the merits of including
all relevant clinical documentation in the record, how the physician's
clinical judgement and medical decision-making as well as complexity of coming
up with diagnoses and associated plan of care is best captured through
reporting of accurate and complete diagnoses reflective of the physician's
work performed from both a cognitive and physical perspective (time and
effort). To this end, the physician will hopefully understand the "what is in it
for me" concept and practically speaking the number of queries that need to
be generated for clinical clarification should trend down over time.

I see the role of the CDIS more in line with educating physicians on best
practices of clinical documentation, carried out through a multitude of
different mechanisms, complemented by queries.

Just some food for thought and consideration.

Thanks

dvitalone1

We have that problem here. I have placed up to 6 queries on 1 record (not all for the same doctor) for specificity.

robert.hodges2

Same issues and I query on all of them unless they indicate in their note that they are waiting for a test result to come back. Of course my providers know that very well now, so I rarely have to ask.

Robert

Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
 
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
 
"We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley

ashlee.gunby

Thank you! I needed some reassurance

Ashlee Gunby, RN
Clinical Documentation Analyst
Doctors Hospital-Augusta
(706) 651-6759

jlindsey

We use a severity status query that works great! We give them back the diagnosis they used and their options are:

Subacute
Acute
Acute on Chronic
Chronic
Other
Unable to Determine

Great response to it.

Jill Lindsey, RN, BSN

Phoenix Children's Hospital
Clinical Documentation Specialist

dvitalone1

WOULD YOU MIND SHARING YOUR QUERY?

paxneros

Sometimes rather than leave a bunch of queries its better to just find the
MD and have a chat about "acute" hospitals taking care of "acute"
conditions. This tamps it down for a while...but it creeps back eventually.
Then its time to chat again.


NBrunson, RHIA, CCDS
Sent from my Verizon Wireless Phone

jlindsey

Not at all. I attached the body of the query. Hope it helps!

Jill Lindsey, RN, BSN

Phoenix Children's Hospital
Clinical Documentation Specialist
602-810-4197
Ext. 3-0725

ashlee.gunby

Jill,
Thank you! It is great to have resources like you and the other members of this talk group!!

Ashlee Gunby, RN
Clinical Documentation Analyst
Doctors Hospital-Augusta
(706) 651-6759

jlindsey

You are right, Ashlee. I am intrigued by your CDI title....Analyst. I like it and haven't heard it before!

Jill Lindsey, RN, BSN

Phoenix Children's Hospital
Clinical Documentation Specialist
602-810-4197
Ext. 3-0725

evanspx@sutterhealth.org

Re: CKD, we are experiencing tremendous positive responses when we ask
for the STAGE of the CKD - our forms incorporate the GFR.

Some positive feedback for specificity of nutritional status as well as
anemia - however, CKD is very common secondary, so many opportunities.

Incorporating the staging based on GFR very helpful for CDI team and
physician team as well.


Paul Evans, RHIA, CCS, CCS-P

Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org

evanspx@sutterhealth.org

The language here would be particularly helpful in regards to language such as "H/O DVT/PE", as just one example, given this could mean many things to a coder.





Paul Evans, RHIA, CCS, CCS-P

Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org

robert.hodges2

I agree. We already have a "slash use" query here, this is a nice supplement to that.

Thanks for sharing Jill

Robert

Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602

jlindsey

My pleasure. Like I said, it works wonders for us here! Hope it does the same for you.

Jill Lindsey, RN, BSN

Phoenix Children's Hospital
Clinical Documentation Specialist
602-810-4197
Ext. 3-0725

paxneros

Did someone mention having a "Versus" (vs.)query? If so - please share -I would appreciate!

Unknown

Speaking of Queries, if they are not part of the medical record, do they need to be saved? I am in a discussion with our Physician Advisor who believes that we must keep all queries.
Thanks for your help.

Jane

robert.hodges2

I don't have a "Versus" query, presuming that would be used when a provider documents multiple diagnoses. I would probably use one of our signs and symptoms queries based on what is documented or a general query for that.

Regarding saving queries not part of the record, we do have that requirement. We save them in the electronic system we use to generate queries to include responses. They do come in handy when outside coding audits occur or an insurance company has a question in the future. They are also available should you go back and audit your queries for appropriateness.

Robert

Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
 
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
 

paxneros

--Motorola-A-Mail-3_5GEcX7Y0Iy-Oho
Content-Type: text/plain; Format="Flowed"; DelSp="Yes"; charset="US-ASCII"
Content-Transfer-Encoding: 7bit

I would like to know the answer to that as well... we have been saving ours
(boxes, boxes, boxes....) for 3 years! I like what some are doing w/ the
"business" secttion of their records but I just wonder how long it will be
before RAC finds them there...?

NBrunson, RHIA,CCDS

vdavis2

All of our queries are part of the legal medical record… We keep our CDS information for 4 months and then shred it. –Vicki

Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Alamance Regional Medical Center
Office (336) 586-3765
Ascom Mobile (336) 586-4191
Fax (336) 538-7428
vdavis2@armc.com

"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens

don.cdi.rn@gmail.com

Our concurrent (CDI) queries are not part of the legal medical record,
but are scanned and part of the administrative or business record.
Frankly, expect RAC / whomever to find them & OK with that -- part of
the reason to save them is to be able to demonstrated appropriate query
practices.

Our retrospecitive (coding) queries are part of the legal medical
record.

One of the key differences to us -- concurrent queries are in the midst
of the stay (and thus we want continued documentation in progress notes)
while retrospective queries are the attending's final opinion.

For the point of how long to hold -- would at the least hold them for
the timeframe that RAC can review records -- so a rolling 3 years or
so.

Seems to me to be prudent to keep -- as long as we are appropriate &
compliant, nothing to hide and would make it much easier to stand up to
any potential scrutiny or question.

I am not aware of any specific regulatory requirement to hold
queries...but personally consider it to be best practice.

Don

vdavis2

Love your Answer Don!

Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Alamance Regional Medical Center
Office (336) 586-3765
Ascom Mobile (336) 586-4191
Fax (336) 538-7428
vdavis2@armc.com

Unknown

We are not allowed to introduce new diagnosis. Our facility considers it
leading. We may however list the abnormal clinical findings and ask if
there is a diagnosis related to it? We also give time for the h/p to be
on chart ( we are EMR) prior to querying. Not sure if this helps! Thanks
for all those who take time to contribute to the CDI talk. It is a life
saver! Jamie



Jamie Dugan RN

Clinical Documentation Improvement Specialist

Baptist Health System

office:904-202-4345

cellular: 904-237-7253

Business Email-jamie.dugan@bmcjax.com

katysuegood@gmail.com

I would make note of these clinical indicators in my personal worksheet but I would not query until I had an H&P.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

afloyd

We don't review until 48 hours after admit to give the MD's time to document H&P, consult note, etc for this very reason. I would note but wait for documentation. Without documentation I would leave it alone unless I found treatment or further monitoring of the suspected condition, then would query requesting a dignosis of the condition being treated/monitored....

April Floyd, RN, CCDS

evanspx@sutterhealth.org

We follow AHIMA Practice Brief, portion of which states:

"As a result of the disparity in documentation practices by providers, querying has become a common communication and educational method to advocate proper documentation practices. Queries may be made in situations such as the following:

* Clinical indicators of a diagnosis but no documentation of the condition"


We wait 24-48 hours after admission to perform the initial CDI review.




Paul Evans, RHIA, CCS, CCS-P, CCDS

Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org

vdavis2

That goes for us too Paul! J

Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Alamance Regional Medical Center
Office (336) 586-3765
Ascom Mobile (336) 586-4191
Fax (336) 538-7428
vdavis2@armc.com

vanessa.falkoff

In this situation, we would not query without the H&P.





Vanessa Falkoff RN

Clinical Documentation Coordinator

University Medical Center

Las Vegas, NV

vanessa.falkoff@umcsn.com

office 702-383-7322

cell 702-204-0054

tpeyton

No, I would wait for H/P



Tracy M Peyton RN, CCDS
Bradford Regional Medical Center
Upper Allegany Health Systems
116 Interstate Parkway
Bradford, PA 16701
814-558-0406

Unknown

Hi Colleen,
We don't review a chart until the patient has been in house for 48 hours so that we have enough documentation to work with. In that situation I would wait for at least the H&P, and maybe some further labs to see what the trend is.
Have a great day,
Lori Harbison LPN CCDS
Quality and Education Coordinator CDI
Cleveland Clinic

lprescott

You have to be careful in asking questions before the physician has time to react to new data available. I don't believe any record should be queried prior to the H&P being added. We also refrain from asking queries based on lab results etc until we know the physician has had the opportunity to view and document their interpretation. Then we query if data is missing.
Laurie L. Prescott RN, MSN, CCDS
lprescott@morehead.org

cnolan@swgeneral.com

That is my belief and training; however that is not quite the rule of thumb here.

cnolan@swgeneral.com

Exactly...but I am meeting resistance..

fantins

Do you have a short LOS? Concerned about missing something if you are waiting 48 hours to review a record.

Susan

lprescott

Your doctors will get irritated with the number of queries and when you really need them they won't respond appropriately. Perhaps if you use that as your arguement it will help.
Laurie L. Prescott RN, MSN, CCDS
lprescott2morehead.org

lprescott

Jamie we were not allowed to bring up new diagnoses either but within the last year using the AHIMA brief on query process our consultants have brought to light you can introduce your clinical indicators and give multiple choice answers that must include diagnoses that will impact DRG, diagnoses that will not impact DRG, other and unable to be determined.

The doctors love this as they felt we were sometimes writing in a foreign language.
Laurie L. Prescott RN, MSN, CCDS
lprescott@morehead.org

cnolan@swgeneral.com

Yes, good point; but usually see an H&P after 24hrs. Unfortunately, number of queries and not necessarily appropriateness are held in high regard. I have encouraged auditing each other, though awkward; plan is to have our physician champion audit. And yes, I have stressed the caution re: physicians becoming irritated with number of queries.

cnolan@swgeneral.com

I just reviewed also; the example being patient admitted with PNA and requesting PNA, sepsis, etc....was surprised that was considered appropriate.

lprescott

You need to assure you have clinical indicators supporting the diagnoses you are querying for. for example if you are asking for sepsis you need to demonstrate SIRS criteria being met. The offer the choices of sepsis, localized infection only, bacteremia, .... and of course other and unable to determine.

Laurie L. Prescott RN, MSN, CCDS
lprescott@morehead.org

cnolan@swgeneral.com

Exactly!! But again we are all on a different page here; my reason for

paxneros

We use HCQ queries from Dr. Pinson and Cynthia Tang,RHIA, CCS which may be found on their website:

Website: hcareq.com

Just make sure you give them credit "HCareQ© Used with Permission".

Thanks,

Norma T. Brunson, RHIA,CDIP,CCS,CCDS

katysuegood@gmail.com

Many of mine are available under 'form and tools' on the ACDIS site. Hope they are helpful

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

debra.stewart@halifaxregional.com

We made some of our own from other examples, I would be glad to sent to you to review and see if you like. Let me know I will send to your email.

angelisa.romanello

Hello Elaine,
We use Meditech for our documentation however our queries are placed in HPF which is a McKesson product.


Thanks
Lisa Romanello, RN,BSN,CCDS

tpeyton

we use meditech but are still hybrid and have paper progress notes. My clarifications still go on the chart in front of progress notes.

Tracy M Peyton RN, CCDS
Bradford Regional Medical Center
Upper Allegany Health Systems
116 Interstate Parkway
Bradford, PA 16701
814-558-0406

paxneros

Hmm... How does that query process work w/HPF, Lisa? We have Mckesson HPF also but still use paper queries. Our charts are hybrid - paper on the floor (Progress notes/Drs. Orders) we can get most of the "cold-fed" documents on Horizon Physician Portal.

How limited are you when designing or tailoring your queries?

Norma T. Brunson, RHIA,CDIP,CCS,CCDS

angelisa.romanello

Norma,

HCA has query forms which are pre-designed. We use a part of HPF called From Fast and we can access our query list and select one of 20 queries.
Then we fill in the clinical indicators and hit submit.
From there it goes directly to the physicians deficiency list.

Lisa

jolene.file

Hi Elaine!

That topic of Meditech & queries is on the agenda for discussion on the ACDIS call today. If you look back on the CDI/talk, there may also be a thread with the prior discussion about Meditech queries which could be helpful.

We currently use the Meditech query and have had a very good physician response rate. We have been using the Meditech electronic query since February 2014 and find it takes longer to prepare a query as we put it in both CDIS and Meditech but our response rate has greatly improved. Julie Bovard, an ACDIS member, provided us with some resources which were very helpful for our IT folks in setting up the query process. I don't know if she still has the info or would be willing to send it to you as well.

I would need to talk to my HIM Director before I could provide any contacts from our facility who may be of assistance.

Jolene File,RHIT,CCS,CPC-H,CCDS
Documentation Improvement Specialist-Coder
Hays Medical Center
jolene.file@haysmed.com

paxneros

Thank you for your reply Lisa!

We also have Form Fast - and I believe our queries are being adapted through this as well. I just wonder if it's as user friendly to move around in as MS Word. I tailor almost every query I issue - because no case is exactly the same. I actually have some queries tailored to specific physicians

Have your physicians become more responsive since you've become electronic? I hope ours won't just "process all" the query deficiencies like they do their other deficiencies.

Any chance you are moving to Paragon in the future? Our implementation is in September.

Norma T. Brunson, RHIA,CDIP,CCS,CCDS

vanessa.falkoff

We made about 14 queries for forms fast in HPF over a year ago when we started going to EMR, and we do not have the option to edit them, free text, or for the physician to free text at all – only check a box. CDI does paper queries and they have all been updated in the last few months, but unfortunately the coders are still using the old queries.
We are struggling with the contractor for improvements, but apparently a lot of things “weren’t included in the package” the county purchased.
Luckily, we are blessed with physicians who are cooperative to the process we have in place and they do seem to be responding!

Vanessa Falkoff RN
Clinical Documentation Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322

angelisa.romanello

Hi Norma,
We have no plans to move to Paragon. We hope to actually see EPIC here some day !

We have 19 “canned” queries and 1 which is our general specificity.
This query allows us to ask a specific question and present the clinical indicators which led to this question. Traditionally we use it for things such as encephalopathy, functional quadriplegia, abnormal lab values.

Our rate of response increased by 25% from the physicians when we went electronic. They actually like this better since they can answer queries from their office and/or home. They are not confined to the nurses station or where ever the chart is located.

Good Luck with your process.

Lisa



Lisa Romanello, RN,BSN,FNS,CCDS
Manager, Clinical Documentation Improvement
Quality and Compliance
CJW Medical Center
804-228-6527
AHIMA Approved ICD-10 CM/PCS Trainer
Angelisa.Romanello@HCAHealthcare.com

Unknown

Any help would be great! Do you happen to have Julies contact information? Thanks!

Elaine Sakala RN
Clinical Documentation Specialist/UR
Delta County Memorial Hospital
esakala@deltahospital.org
970-874-2287

rachel.layne.mack@gmail.com

1. Who is responsible for concurrent queries? At our institution it is the CDI who is responsible for concurrent queries (most of our CDI staff are RNs, though we do have a small percentage of other mix of staff).
2. Who is responsible for retrospective queries? The coder is responsible for retrospective queries.
3. For those programs where CDI is responsible for all queries what are the benefits/issues. What is your process? I think there would be great benefit in having CDI more actively involved in sending retroqueries when needed. Right now coders do occasionally contact the CDS if they need to send a retroquery, but not always. If there was a streamlined communication - because the CDI is so familiar with the case, and because most coders have such productivity metrics they have to meet - the CDI and coder could formulate the query together and create the best query possible for asking the question.

I think all institutions should reevaluate their query process frequently - Good Luck!

Rachel Mack, MSN, RN, CCDS
Clinical Documentation Integrity Educator
CDI Supervisor - St. Vincent, St. James, & St. Francis
SCL Health – 12600 W. Colfax Suite A-250, Lakewood, CO 80215
rachel.mack@sclhs.net
303-403-7925

katysuegood@gmail.com

For our facility, I encourage CDI's to place ALL queries though the coder can choose to place retro queries themselves if they would rather. We review 100% of inpatients so we do not have the issue of the CDI having to review a record that they didn’t review concurrently in order to place a query. There are a few reasons why I prefer CDI place the queries.
1. Consistency- CDI develops all the query templates and is more invested and familiar with how/when they should be placed.
2. Feedback- A retro query (in our case-we DO review D/C summaries) is generally a missed opportunity for concurrent clarification. I find it VERY important that the CDI's know when the coder felt additional clarification was needed. This is GREAT education for CDI.
3. Resources- our CDI team is well-staff and well-connected with the physicians. When we place the query we track it and make sure it gets answered. If coding places the query and the MD does not respond in a timely manner, the coders do not have the time/ability to reach out to the MD's the way we do.

Thanks!

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

ddouthit

CDI does not do 100% reviews. We review about 97% of our Medicare population and about 55-60% of our non-medicare population.

1. CDI generates all concurrent queries and follows the query concurrently and then retrospectively if not completed prior to d/c.
2. CDI generates all retrospective queries. If the coder identifies an account that they feel needs a query it comes back to CDI for review and determination if a query is warranted.

There are many benefits to CDI generating all queries.
The verbiage of the queries are consistent.
Education opportunities for the CDI and coder.
Encourages dialogue between the coder and CDI.
Physicians only have to deal with the CDI staff and we already have a repore with the physician.

Downside:
Very time consuming for the CDI.
Takes away from concurrent reviews if CDI department has staffing issues.


Dorie Douthit RHIT,CCS
AHIMA-Approved ICD-10-CM/PCS Trainer
ddouthit@stmarysathens.org

vanessa.falkoff

1. Who is responsible for concurrent queries? CDI RN

2. Who is responsible for retrospective queries? Coder- sometimes I help them.

3. For those programs where CDI is responsible for all queries what are the benefits/issues. What is your process? I think our query process would run more smoothly if CDI did them all, it just isn’t a realistic option with our current resources. I also think that in the long run the more productive solutions to our issues is to increase the coders query skill set.

Vanessa Falkoff RN
Clinical Documentation Improvement Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322

jriley

Coders query retrospectively but only in cases where there is potential DRG impact. They do not requery CDI queries with no payment impact if they remain unanswered at discharge. CDS's query concurrently. The CDS's and coders work very well as a team and complement each others' knowledge. All our queries are reviewed and approved as a team. We meet monthly as a group and find that this strengthens communication and avoids the "us vs them" mentality that often exists between the two departments.

Judy

Judy Riley
Coding/CDI Mgr
LRGHealthcare x 3315

Unknown

Our CDI Specialists are responsible for all concurrent queries. Coders will, at times, send retrospective queries but our policy is that if they don't receive a reply from the physician within three days, the query is sent to CDI for follow-up. There are times the coders ask for assistance in wording a retrospective query and we help them with that.

We are very fortunate to have a great relationship with our coders and this process seems to work very well.

Linda

Linda Haynes, RHIT, CCDS | Manager, Clinical Documentation Improvement | Legacy Health
19300 SW 65th Ave. | Tualatin, Oregon 97062 | 503-692-8862 | lhaynes@lhs.org

kathryn.good

Can you provide an example of one you have been told is leading?

Thanks!

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

chutchinson

I use templates.
Who is saying the query is leading? Could you provide an example of your "open ended" "leading" query?

Claudine Hutchinson RN (CDI)

kathryn.good

Stephanie,

Can you provide an example of a query you are being told is leading. Also, who is providing the feedback?

Thanks!

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

hillsandovals@email.chop.edu

I have submitted a few examples, also we were told by our physcian advisor who will be over us.

hillsandovals@email.chop.edu

here are some examples of our queries

The Clinical Documentation team has identified an opportunity for clarification in the medical record of the above patient. According to the Admit/H&P:

•XXXXXX is a 12 year old female with , malnutrition, underweight and Medical Instability: Bradycardia and has had a 20 lb weight loss over 8 month(s). XXXXXX is being admitted for: malnutrition, underweight and bradycardia and has had a history of Restricting accompanied by signs and symptoms of malnutrition, exhibiting: cold intolerance, fatigue/lethargy and dizziness.

Her diagnosis was documented as malnutrition. If, in your clinical opinion, XXXXXX's malnutrition rises to the level of either moderate or severe, please use that diagnosis in your future progress notes and discharge summary to accurately capture the severity of illness of your patient.



eg 2)

According to your notes, the below diagnoses, signs and/or symptoms were documented. However, a more specific condition might apply to this patient. In order to capture accurate risk of mortality and severity of illness, any information that can be added to clarify the information below, which supports the clinical picture of this patient, is appreciated. Please provide this documentation in your future progress notes and discharge summary.
Madison is a 10 year old with CP, neuromuscular scoliosis, and multiple contractures. According to your PICU admission note,
• She has “obstructive sleep apnea….a history of intermittent CPAP use at her long term care facility for extrathoracic airway obstruction.”
• On the regular inpatient care area, she had an episode of hypoxemia and reported apnea. CAT was called. The decision was made to transfer to the PICU for CPAP titration to prevent hypoxemia
• Her home baseline CPAP settings were increased from 8 to 14.

In your clinical opinion,
• does this patient have chronic respiratory failure, due to her airway obstruction caused by her musculoskeletal condition, as evidenced for her baseline need for CPAP;
• if so, does her post-op course rise to the level of acute on chronic respiratory failure, as evidenced by her need for increasing CPAP support and the need for PICU level of care.