RAC and Queries that are not a permanent part of MR
We’ve just now gotten our first big RAC audit and they specifically requested queries. Our queries (CDI and coding) are not a permanent part of the medical record. We are pulling ours to submit, but the Coding Supervisor says since the queries are not a permanent part of the medical record, she is not going to submit the queries written by the coders. My question is, how will this affect the audit?
Thanks in advance for any advice!
Sharon Cole, RN, CCDS
CDI Specialist Team Leader
Providence Health Center
254.751.4256
Sharon.cole@phn-waco.org
Thanks in advance for any advice!
Sharon Cole, RN, CCDS
CDI Specialist Team Leader
Providence Health Center
254.751.4256
Sharon.cole@phn-waco.org
Comments
Is the RAC asking for queries that are a part of the medical record or for your non-permanent queries?
I would think that unless ypur queries are part of the record you wouldn't need to provide the copies of your non-permanent queries.
Are they paper copies or have they been scanned to a business area of the chart?
Thanks,
Norma T.Brunson, RHIA,CDIP,CCS,CCDS
First of all, we have a hybrid record, so the queries are paper and are not a permanent part of the medical record (it even says so on the query). At discharge, once the coding is complete, the coders send the query back to us (we work out of case management) where we store them in the office for a year, then send to long term storage for several years (per hospital overall policy). The CDI queries are created and saved in Allscripts – which is the program we document in, but it is not considered a part of the medical record either. Our patient records are in Epic.
***yes, very confusing I know.
Sharon Cole, RN, CCDS
CDI Specialist Team Leader
Providence Health Center
254.751.4256
Sharon.cole@phn-waco.org
We are also Hybrid with CDI Queries being paper and NOT a permanent part of the record. Our Queries also state, "Please do not respond on this query as it is NOT a permanent part of the record."
Once the patient is discharged we log responses into our software and the paper copy goes into a box and into storage. We haven't really decided on a retention policy at this time. As the info. is available in our software they could be destroyed. We've talked of scanning them into the business section. Right now, they rest in boxes.
Our Coding queries ARE a permanent part of the record. If Coding has to query post-discharge the query and response is scanned into the permanent record. I can see these being subject to RAC reviews.
But for queries which are not permanent... I would be reluctant to provide copies.
NBrunson,RHIA,CDIP,CCS,CCDS
Sharon Cole, RN, CCDS
CDI Specialist Team Leader
Providence Health Center
254.751.4256
Sharon.cole@phn-waco.org
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