RAC, queries, and the new Practice Brief
In the new Practice Brief, under the section: Develop Query Retention Policies, the very last sentence states: Auditors may request copies of any queries in order to validate query wording, even if they are not considered part of the legal health record.
Our queries are not considered a part of the legal medical record, but are retained in the office for 1 year and then sent to long term storage for 6 years. If a physician answers on the query ONLY, the diagnosis is not coded by our coders.
Based on the above sentence in the new practice brief, if the auditor requests queries, do we send them? If we do not, can we be penalized for not sending them?
Sharon Cole, RN, CCDS
CDI Specialist Team Leader
Providence Health Center
254.751.4256
Sharon.cole@phn-waco.org
Our queries are not considered a part of the legal medical record, but are retained in the office for 1 year and then sent to long term storage for 6 years. If a physician answers on the query ONLY, the diagnosis is not coded by our coders.
Based on the above sentence in the new practice brief, if the auditor requests queries, do we send them? If we do not, can we be penalized for not sending them?
Sharon Cole, RN, CCDS
CDI Specialist Team Leader
Providence Health Center
254.751.4256
Sharon.cole@phn-waco.org
Comments
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
Carol Canipe RN, BSN, CCDS
Clinical Performance Improvement
704-834-4980
Caromont Health
Gastonia, NC 28053
queries; they already do that. It was included simply to acknowledge
that some hospitals choose to not make queries part of the permanent
record. Each hospital is advised to make a policy about record handling
and retention of queries that are NOT part of the permanent record.
Hospitals that classify queries as a business document would handle them
according to internal policy.
Cathy L. Seluke, RN, BSN, ACM, CCDS
Supervisor Clinical Documentation Compliance
MaineGeneral Medical Center
Augusta and Waterville, Maine
P. 207.872.1796
F. 207.872.1594
Cathy.Seluke@mainegeneral.org