Concurrent Query physician response
Good Morning!
Looking for best practice ideas please.
Our concurrent queries are a part of our permanent record.
Currently we ask the physician to document a response to our query in the body of the medical record. However, often times the physician will document a response on the concurrent query.
This creates a problem as our concurrent query form states "document response within the body of the medical record".
Question 1
Do you allow your physicians to document response on the concurrent query?
Question 2
If a physician is allowed to document on the concurrent query form, do you find that they pick up this diagnosis and begin documenting subsequently in the progress notes?
Question 2
If physician must document response in the body of the medical record, what "written instructions" on the concurrent query do you give the physician?
Thanks,
Dorie
ddouthit@stmarysathens.org
Looking for best practice ideas please.
Our concurrent queries are a part of our permanent record.
Currently we ask the physician to document a response to our query in the body of the medical record. However, often times the physician will document a response on the concurrent query.
This creates a problem as our concurrent query form states "document response within the body of the medical record".
Question 1
Do you allow your physicians to document response on the concurrent query?
Question 2
If a physician is allowed to document on the concurrent query form, do you find that they pick up this diagnosis and begin documenting subsequently in the progress notes?
Question 2
If physician must document response in the body of the medical record, what "written instructions" on the concurrent query do you give the physician?
Thanks,
Dorie
ddouthit@stmarysathens.org
Comments
response. We also ask them to document in the medical record. Our
queries are scanned into the actual record. Thanks Jamie
We DO allow MD's to document on the query. We also ask them to add to their progress notes however, I often find that it is not carried through. This is a BIG problem. For example, if I query for Sepsis and they respond positively but then it is not carried through the record, this poses a big issue for coding. I think it is less of an issue if the query is for additional specificity (ie: severity of malnutrition), but it is a hige issue if it is a diagnosis that is not otherwise in the chart.
I am definitely curious how other facilities are handling this issue.
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
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
“Patriotism is easy to understand in America; it means looking out for yourself by looking out for your country" Calvin Coolidge
Our coders pick up the dx from the query as it is part of the record as
well jamie
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
with this practice since we have only been up for one year! Glad to see
you back on
Our queries are a permanent part of the medical record. I think there are obviously some real pro's and con's for having them there, but I think the biggest is a "pro" and that it helps support resource consumption for a disease process, and for quality-DOES provide a more complete medical picture (helps o/e ratios) etc. Our consultant has stated over and over, that as long as we give an "other/unable to determine" on a query, that we are not leading them! So for us, if it is on a query-even if it is not carried through, and we have used the resources, and there are adequate clinical indicators, WE USE THAT DIAGNOSIS.
Having said that, I AGREE TOTALLY. We too have problems with asking a question on a query-getting a positive response and then NEVER having it documented again. For some reason, it is the majority of Sepsis queries! We even have physicians who document it on day of admit and then NEVER again...we leave a gentle reminder to continue to please keep documenting those diagnosis as "ruled out, resolved or a current diagnosis". It is especially difficult because the LARGEST part of our physician group are HOSPITALISTS (many locums who only work 2 days a month or 2 weeks a month and then do not return for months), and any one provider does not, or WILL, not take another diagnosis AWAY from another provider, or support a diagnosis that has resolved before he has seen the patient...tracking down a doc who gave a diagnosis the next doc did not carry forward is a cluster!
Juli Bovard RN CCDS
Certified Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
719-4390 (work)
786-2677 (cell)
"No Limit to Better......"
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
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
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
is precious!
Jamie
We do not keep our CDI queries (concurrent) as a permanent part of the Medical Record. If the Coders need to issue a query Post-discharge, this query and response will be scanned into the Medical Record.
So naturally we do not want them writing on the query when they respond. Our concurrent CDI queries state:
"Please do not make your response on this query as it is not a permanent part of the Medical Record."
However, this will occasionally happen and I followup on the query with a note to the physician to respond w/in the medical record. Sometimes they will- sometimes they won't.
Our queries also include language such as:
"Please document within the Medical Record..."
"Clarify the appropriate likely diagnosis within the Medical Record."
We hope this encourages them to follow instructions.
NBrunson, RHIA,CDIP,CCDS
Jill Lindsey, RN, BSN, CCDS
Phoenix Children's Hospital
Clinical Documentation Specialist
Ext. 3-0725
Concurrent CDI queries are NOT part of the legal medical record. Physicians are welcome to reply as a means of communication, but any additional documentation is not coded unless placed into the record.
Coders will, if necessary (single documentation point, conflicting documentation, response only to the electronic CDI query) re-present the query to the physician after discharge.
Coding queries are part of the record.
However, I do hold the standard that our concurrent CDI queries WILL be compliant, and we will assume that at some point they may well be 'discovered' -- and are very open to that.
There are very much two sides of the coin. In part, by requiring a response in the record (fully electronic), I believe we more often see a trend established (as opposed to single documentation points).
Our instructions are very similar to others.
Don
As long as there is a Policy in place that states the q's will be part of the medical record per health system HIM policy I think it will hold up.
Here is one reference from Coding Clinic, and it should be applied in context - we need our documentation to be 'consistent and reliable' so that the coding decisions can be 'defended'.
Having said that, here is one reference from AHA Coding Clinic
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
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
“Patriotism is easy to understand in America; it means looking out for yourself by looking out for your country" Calvin Coolidge
We are just persistent when it comes to unanswered queries and we always teach that all secondary diagnoses must be written twice. Our queries are discoverable but not a permanent part of medical record. I must admit, in our relentless pursuit of a rock solid chart, my nurses have become bulldogs to some extent. That said, the squeaky wheel gets the grease! A main focus of ours is effective communication with MDs. We give them copious gratitude, feedback, and occasional goodies so the relationship is strong. I don’t think they find us to be too annoying. Most understand the greater good of our goals.
-Jane
We should also be aware that some 3rd parties do accept coding of conditions 'even if/when' said terms is clearly documented more than once - this causes me great concern.
REFERENCE BELOW IS TAKEN FROM A MEDICARE NEWSLETTER
**********************************************************************************************************
An 81-year-old female was admitted with complaints of dry cough for a couple of weeks. The patient was admitted through the emergency department and was assessed for wheezing and coughing. H&P impression is acute respiratory failure secondary to exacerbation of Chronic Obstructive Pulmonary Disease (COPD). Progress notes through the stay also document the diagnosis of acute respiratory failure secondary to exacerbation of COPD. Final diagnosis on the discharge summary is acute respiratory failure
Auditor finding: After physician and auditor review, it was determined that the clinical evidence in the medical record did not support respiratory failure, despite physician documentation of the condition.
Action: The auditor deleted acute respiratory failure and changed the principal diagnosis to COPD Exacerbation. The auditor deleted respiratory failure code 518.81 and changed the principal diagnosis to hypoxemia code 799.02. This resulted in a MS-DRG change from 189 to 192–Chronic Obstructive Pulmonary Disease without CC/MCC.
(Medicare Quarterly Provider Compliance Newsletter Guidance to Address Billing Errors Volume 1, Issue 4 - July 2011)
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
We seek consistency in rationale, as well as the use of the words ongoing, improving , and resolved. We have had these take back attempts. We are appealing these now. We are also in the process of implementing standard definitions for some of these hot diagnoses to help mitigate these denials. We also, ensure the terms used by MDs (with or without a query) are supported by clinical evidence. This can be tricky and requires the utmost sensitivity, but we have discussed with MDs removing diagnoses that are not well-supported by clinical indicators. Thus far, MDs have been receptive. It brings CDI full circle.
-Jane
It is my contention (I must be brief):
1. Qualified and university-trained coding professionals possess clinical knowledge by way of formal education
2. The coding profession 'must evolve', however, as there is ample evidence coders may, indeed, be called upon to ensure key terms 'meet' definitions. This precedence has already been set.
3. The coding profession must further embrace the Quality Mission
For any of the above to happen, the coding profession must be better valued within the health care environment.
Best,
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
NBrunson, RHIA,CDIP,CCDS
************************************************************* Auditor finding: After physician and auditor review, it was determined that the clinical evidence in the medical record did not support respiratory failure, despite physician documentation of the condition.
Paul,
I would be really interested to know what the clinical picture was on this patient!
Vanessa Falkoff RN
Clinical Documentation Coordinator
University Medical Center
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
cell 702-204-0054
However, the CMS advice did not provide any clinical details about the model case - leaving one to wonder what criteria would satisfy the reviewer?
No Physical Exam or ABG referenced in the scenario.
Reminds me of a saying my Dad would provide to me as a child (I am Roman Catholic, so apologies in advance to any other Catholics)...it went like this, and this was the way my Dad spoke:
"The Pope no playa da game, but he maka da rules, and we gotta follow 'em"
Where does this leave us?
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
Have a great weekend!
Vanessa
Personally, I 'always' double-checked certain key criteria whenever I coded certain conditions - SIRS (surviving Sepsis) -(Complex PNA - antibiotic used ) - Edema of Brain (Steroids, Sodium Levels).
I did this 'defensively' knowing someone else do so externally, regardless of what was written by the Medical Staff.
However, taking such care to code affects productivity. Further, the coders do not operate in a culture whereby confirmation of conditions would be welcomed. For this, and a multitude of other reasons, the industry approach to 'coding' and subsequent data quality must be reexamined, in my opinion.
Some common root causes include the emphasis placed upon a production-line mentality and the classification of some coders as 'clerks' (with subsequent low pay) by HR.
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
We are looking into implementing an alternating home/office schedule; we have three full time CDIS'. One or two CDIS' would be available on-site daily to interact with physicians and place queries on a chart (as we are hybrid also). We are a small community hospital with independent physicians who are rarely available, and not very cooperative.
Any suggestions? Does your facility accommodate this? And if yes, any tips to help sway the director?
Thanks