What CMS has to say about queries

lspryszaklspryszak
in CDI Talk Archive
The website below is a recent RAC 101 presentation by CMS. In the question and answer period (at the end) someone asks about physician queries and whether to submit them with a record request. Very interesting.

https://download.yousendit.com/THE0Y05xeFhCSWRjR0E9PQ

Comments

  • lspryszaklspryszak
    Sorry -- I posted the wrong link. Please disregard the previous
  • dsmith12h@aol.comdsmith12h@aol.com
    edited May 2016
    Do you have the link for this? I am interested in what CMS said relative to queries.

    Thanks,
    Debbie Smith






  • lspryszaklspryszak
    Here is the section from the recent RAC 101 Q/A session on queries:

    "Q: Hello. I have a question about the appropriateness of the physician query being included as a submission when the RAC asks for additional documentation. IÂ’m seeing conflicting information about whether or not CMS has authorized the query to be a part of what needs to be submitted or if that's up to the discretion of the particular contractor.

    EB: Yeah, that would be up to the RAC. They can, you know, based on the issue and what they feel is necessary to do the review. If they ask for something, I mean if they did not ask for something and you think that itÂ’s necessary, then we encourage you to send whatever you think will support paying the claim.

    Q: And IÂ’m referring to sort of I guess itÂ’s a sample letter that HDI has provided that is going to be using, you know, as its ADR and itÂ’s just a blanket request for a variety of documents that it appears the physician query will be requested on a regular basis.

    SW: Again, that language is fairly standardized. CMS is not prescriptive in what we recommend the provider sending forward. I would send anything that you feel would substantiate a valid payment of that claim.

    Q: Is it required that that query be included every time?

    EB: ItÂ’s required that you submit what theyÂ’re requesting but we donÂ’t have a requirement as to what they can request for their review. But if they request that information, you do have to submit it. So in other words if the RAC requests medical records, you need to submit those documents that you believe will support the claim that was billed. Now the RAC provides some suggestions as to what documents are useful in helping them make the determination. If you don't believe the physician query helps to support the claim that was billed, then you don't need to submit it. But the medical records lists some suggested things that you should submit that does help the RAC to make the determination."
  • Unknown
    edited May 2016
    Rac review---the patient was admitted with acute confusion, acute renal failure, and dehydration. CT scan of the brain showed old ischemic changes. He was given fluid and his kidney funcition improved. He was seen by neurology and had an EEG which was normal. BUN was 50. The final diagnosis was acute renal failure and acute confusion secondary to dehydration. We coded acute renal failure with acute confusion and dehydration as secondary diagnoses. The RAC is taking away the secondary diagnosis of acute confusion since the acute confusion was determined to be secondary to the dehydration. They cite coding clinic 2007 third quarter "if a symptom is an integral part of a disease process, the symptom would not be coded". We argued in our discussion call that acute confusion is not present in every patient with dehydration and is therefore not an integral part of the dehydration. This case did go to a physician reviewer at the RAC who agreed that the confusion was secodary to the dehydration. Would you appeal this case based on coding guidelines stating that signs and symptoms not routinely associated with a disease process should be coded when present?

    Debbie Loeffler, RHIA







  • jolene.filejolene.file
  • Unknown
    edited May 2016
    I would appeal also. I think they are pulling at straws to win the issue. The coding clinic they refer to is a such:
    Conditions that are integral to a disease process should not be assigned as additional codes. This guideline applies to all healthcare settings. For example, nausea and vomiting should not be coded in addition to gastroenteritis, because these symptoms would be considered integral to a diagnosis of gastroenteritis. Similarly, wheezing should not be coded in addition to a diagnosis of asthma. Conditions that are considered integral to a disease process are not always included in Chapter 16 of ICD-9-CM. For example, pain or stiffness in a joint, which are found in the Musculoskeletal chapter of ICD-9-CM, would be considered integral to a diagnosis of arthritis. Conversely, conditions that may not be associated routinely with a disease process should be assigned additional codes. It is a fact that NAUSEA and VOMITING is present with GASTROENTERITIS, and the same with ARTHRITIS and JOINT PAIN/STIFFNESS. However, the same can't be said for confusion and dehydration.


    Malinda



  • pfowlerpfowler
    edited May 2016
    I thought if is written as a symptom of the diagnosis it would not be
    coded separately. If the physician had not documented "secondary to
    acute confusion" then it could be coded that way. That is the way I read
    the coding clinic explanation.



    Patsy Fowler RN, MSN, CCDS

    Certified Clinical Documentation Specialist

    Marion Regional Medical Center

    PO Box 1150

    Marion, SC 29571

    Office 843-431-2044

    Cell 843-431-2863

    Fax 843-431-2475




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