Superfluous queries?

What are your thoughts on when a query is indicated? Do you primarily query only when there is:

1. Potential CC/MCC

2. POA clarification

3. Complication clarification

4. Dx that may significantly impact SOI/ROM

5. Culture specificity/underlying cause

6. Other specific circumstances at CDI discretion

Or, do you query for specificity anytime it is available in the code set?

For example:

1. If you have a patient with DM with no indicators that this is uncontrolled. Do you query for Type I vs type II just for clarities sake?

2. If you have a pt with low potassium that is repleated per protocol, do you query for this dsx if only 'low potassium' is documented or do you primarily query on lab values that carry weight (hyponatremia)?


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

Comments

  • edited April 2016
    At our facility ,we query for everything! We look at all all payers.

    Sent from my iPad

  • We would query only when it meets the definition of a reportable diagnosis:

    clinical evidence should be present in the medical record to support
    code assignment. The Uniform Hospital Discharge Data Set (UHDDS) Guidelines for coding and reporting secondary diagnosis allow the reporting of any condition that is clinically evaluated, diagnostically tested for, therapeutically treated, or increases
    nursing care or the length of stay of the patient.

    If you literally interpreted guidelines to query for a higher level of specificity per the ICD-9-CM codes, looking through the DRG expert you could easily issue 50 queries on each record. This would obviously result in query fatigue from your providers.

    I noted the same thing when I saw a demo for CAC with NLP. The representative dictated a two sentence paragraph and 7 "prompts" appeared. I thought to myself-what happens with an H&P. If that was the right approach you would need CDIs with critical thinking skills to determine what needs clarification and what does not.

    http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1121.pdf


    Just my two cents...
    Charrington "Charlie" Morell
  • Clarification: you would NOT need CDIs with critical thinking skills-sorry, haven't had my coffee yet :)
  • We review all payers too. I want a program devoted to quality. But I think we also have to be realistic about the burdens placed on providers. So in my mind queries that have no impact on the record (I am not talking about just dollars here) seem superfluous. But honestly, I am just unsure what is 'normal' in the industry. So for the query examples listed below, I would suggest that a query should only be placed for DM is there is evidence that it is uncontrolled. Or I would query for hyponatremia if it was treated but I would likely only query for hypopotassemia if it was a big issue in the record but probably not if it was just repleted per protocol once. Sure, it’s a valid dx but not something I am going to press the MD on.
    I am just not sure what is right here. We are a moderately established program but work with mainly hospitalists who have been very receptive to training. We review all inpatients and all payers so some of those areas are low impact and our query rate is roughly 15% with a focus on education not just queries. But we recently have one CDS approach close to 50% for her query rate and I noted a lot of this type of query which my other CDI's do not place. We are measuring query rate as query/reviews and we average 2 reviews per patient with an average LOS of 5 so this literally means on average a query is placed on every chart. To me, this is too much. We have doctors grumbling...

    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

  • edited April 2016
    We follow the guidelines , we probably need to work more with educating or physicians.

    Sent from my iPad

  • Brief Response: Any us could query 'every' case - but, this leads to query fatigue. I think of an issue for:

    DRG - Reimbursement
    ROM/SOI
    Educational Component - ICD -10 and/or 'common' theme for high-risk or high volume topics.

    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002

    evanspx@sutterhealth.org


  • Oh Boy. I so hate to disagree with some of my favorite CDI talkers. Forgive me. But, I need to in this case. I get what you are saying. I get query fatigue. I get that we could query on every and all charts. But shouldn't we? I want a program founded and grounded in Quality. I want the providers to understand that the care they provide at the bedside is as important as the way they document that care. Am I a CDI Geek? Yes. Maybe:)
    ICD-10 is ALL about this specificity. If we have unspecified DM going out into the coded data world, how does that help research for the little 10 year old with Type 1? It won't. They can't use unspecified data for research. If it doesn't bring cash or SOI or ROM, we shouldn't query to save the Docs from bother? I say no. It brings granularity. Granularity has tremendous value. My goal is for the medical record to tell the patient's story. The whole story, the right story. Not the easy story. I think we all deserve this in the new age of electronic data. My 2 cents. Again, I hate to go against my mentors. I WELCOME your education to sway my view otherwise:) Thank you.

    Jane Hoyt
    CDI Director
    SCLHS
  • edited April 2016
    Jane,
    I agree with your sentiments. I tell my team there is a fine line and balance between query fatigue and specificity. We are a large facility so many times, the only way to reach a provider is through a query. They deserve the education process as well.

    Like you, I also believe with the upcoming specificity required in ICD-10, we need to ask the hard questions.
    Thank you
    Lisa



    Lisa Romanello, RN,BSN,FNS,CCDS
    Manager, Clinical Documentation Improvement
    Quality and Compliance
    CJW Medical Center
    804-228-6527
    Angelisa.Romanello@HCAHealthcare.com


  • Jane and Lisa,
    Just to clarify-
    You are issuing queries for everything? Queries on conditions that do not meet the UHDDS definition of a reportable secondary diagnosis?

    If so, you may wish to reconsider: I reference this article by one of my mentors-Gloryanne Bryant.

    http://www.hcpro.com/HIM-263777-5707/Tip-Know-when-to-report-secondary-diagnoses.html
  • Please, disagree away! That’s why I am asking the question :). I agree with all of your sentiments which is why I am battling with this issue. Can I ask what your query rate? I honestly believe that if we queried for all specificity available in I-9 (let alone I-10), we would be well over a 50% query rate. I completely understand that the opportunity is there and would like to be consistent across the board but I do think that we have to weigh things carefully. It's interesting that you mention I-10 because our physician liaison has make it very clear that he does not want us placing queries that are purely for code expansion with I-10, especially early on. We have so many changes (we are implementing several new documentation tools) that the MD's are trying to keep up with as is, our MD's are already struggling. I think the backlash would be pretty intense. I realize the implications of specificity on research and metrics and I use this argument with our providers regularly but I think we would have difficulty keeping them engaged in the process if we are unwilling to compromise.
    As a second point, if we as an industry are truly interested in documentation specificity with no other motives, then every program should be all payer/all patient. And this would be true for outpatients too. Right? We (like most programs) started with just Medicare, then added BCBS, and only recently moved to all payer/all patient but only on the inpatient side. It's clear why, this is where the 'opportunity' is.

    Thanks for all the feedback everyone, I appreciate the discussion.

    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


  • edited April 2016
    Hi everyone,

    We are only able to review Medicare and DRG payors at this time, and we do query for clarification of DM I or II as an "educational opportunity" and to capture manifestations related conditions, but mostly we query for clarification or specificity on issues that we believe will impact the clinical picture and most likely the DRG/SOI/ROM.

    Our query rate varies from 14-28% and our response rates are usually 90% or higher, but we are in the painful process of implementing EHR, and will soon go to electronic queries so that may change. I printed out the article referenced earlier to go over with my partner - we need to be as efficient as possible :)

    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

    Compassion * Accountability * Respect * Integrity


  • Hi, Jane

    I understand and appreciate your points - but, it is simply not practical for our team to query at EVERY opportunity. We do not have the staffing - also, I really do want to query the physicians for material (significant) clinical issues - granted, this can be a subjective matter. I think a CDI team needs to be judicious in this matter.


    But, this is not to mean I will not perform an 'educational' query - I will. However, not at every opportunity. To do so is impossible with our staffing.

    This philosophy is addressed in the AHIMA Best Practice below published in 2012.



    Managing an Effective Query Process


    --------------------------------------------------------------------------------

    Note: This practice brief updates the 2001 practice brief “Developing a Physician Query Process,” with a continued focus on compliance.



    When to Query

    Providers should be queried whenever there is conflicting, ambiguous, or incomplete information in the health record regarding any significant reportable condition or procedure.

    Queries are not necessary for every discrepancy or unaddressed issue in physician documentation. Healthcare entities should develop policies and procedures that clarify which clinical conditions and documentation situations warrant a request for physician clarification. Insignificant or irrelevant findings may not warrant a query regarding the assignment of an additional diagnosis code, for example. Entities must balance the value of collecting marginal data against the administrative burden of obtaining the additional documentation

    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002

    evanspx@sutterhealth.org



  • edited April 2016
    I agree with Jane and Lisa
    Judy Gilroy Valitutto,RN CDI since 2007

    Sent from my iPad

  • edited April 2016
    You are nurse after my own heart.
    I hear you loud and clear and agree with you wholeheartedly.Call me old fashion,I believe I the story,I believe in the right thing for the pt.
    Residents change floors , nurses work 12 hrs,continuity can get lost. I am the only one at the desk 5 days a week. I read all of the chart.
    Electronic chart has it pulses ,can run reports,but the emotion is gone ,drop down screen don't always have the descriptions we look for.
    I see it as obligation to query bring topics to the surface,bases on what info is documented in the chart. Proper documentation ,leads to,less quality issues,less mistakes and better follow through and complete chart.i also helps educate the residents.


    Sent from my iPad

  • I think staffing is a great point Paul. If CDI's are to query on every possible opportunity, I would imagine they would be unable to review the same volume of records. Considering most hospitals have limited CDI resources, we will likely have more impact on overall documentation if we review more records and query on significant dx/issues rather than reviewing a smaller volume but querying on the minutiae. I would be interested in knowing the query rates of facilities that are truly querying every time there is available code expansion or additional dx. It seems like it would be VERY high. I am assuming facilities that are doing this have large CDI teams compared to volume so that they can cover all payers to this level and am curious if you have run into any issues 'justifying' your team. We also review all payers and have a large team for our hospital but we are asked about ROI and must be prepared to respond.

    I have enjoyed hearing everyone's feedback and actually find the idea of querying 'all the time' intriguing. We definitely do not have the buy-in to do this now but it's an interesting idea.


    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


  • Queries are not necessary for every discrepancy or unaddressed issue in physician documentation. Healthcare entities should develop policies and procedures that clarify which clinical conditions and documentation situations warrant a request for physician clarification. Insignificant or irrelevant findings may not warrant a query regarding the assignment of an additional diagnosis code, for example. Entities must balance the value of collecting marginal data against the administrative burden of obtaining the additional documentation

    Paul Evans, RHIA, CCS, CCS-P, CCDS
  • I understand all points of view - for my point of view, I do not endorse submitting a query at 'every' opportunity due to the credibility factor, so to speak. I believe one must consider and respect the time and burden it takes the respondent to thoughtfully reply to all valid queries that are submitted. The details that are available in coding can be painfully detailed - and sometimes not truly relevant to the particular episode of care.

    A CDI team only has so much 'political capital' to spend in their efforts - if one submits excessive queries that may not always be clinically relevant, you risk incurring query fatigue syndrome.



    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002

    evanspx@sutterhealth.org

  • What's the I-10 code for 'query fatigue syndrome' Paul? ;-)

    I agree, I'd be impressed with a program that had the clout to sustain a 50+% query rate without backlash but we definitely don’t have that. We have great Dr's and they work with us but I also always reassure them that we understand they are very busy and we only query when it is really needed. This doesn’t mean just for the $$ but I definitely weigh their time input vs the query impact carefully. We are always a high outlier for medical CC/MCC rate, this means most of our queries even for CC/MCC's don’t actually impact $ but they often impact SOI/ROM and they change documentation habits as well.

    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

  • edited April 2016
    Paul and everyone else,
    You make some very important points. We work hard to balance the "accurate medical record" as well as avoiding that of making physicians, "query weary."
    We have 758 beds on two campuses
    We have 5 CDIs
    We have about a 25% query rate.
    We only review Medicare concurrently however : we also review all of the patients in our facilities who have a consult with the wound care team regardless of payor source, all patients who have been admitted with either sepsis or potential for sepsis regardless of payor sources.

    One task we complete which is very helpful in our learning process is that of reconciliation. We reconcile all of our reviews following the assignment of the coding final bill. We then see if the coders had to query for something we missed. Our goal is to help them keep up their productivity by not having to query on the retrospective end.

    It is a true balancing act and we have worked hard in our 6 years to earn the respect of the physicians. It is important for us to obtain an accurate medical record however it is also important to maintain our integrity as healthcare professionals.

    Thanks
    Lisa

    Lisa Romanello, RN,BSN,FNS,CCDS
    Manager, CDI
    Quality and Compliance
    CJW Medical Center
    804-228-6527

  • edited April 2016
    I have also enjoyed reading all of the responses to this thread-thank you Katy for initiating it!
    While our process includes concurrent review for all payors, we are not able to touch every chart. Another similar hot topic at my organization is holding cases post discharge for educational queries. Our coding department feels strongly that regardless of impact on the drg, soi, rom, that if a clinically significant diagnosis is not documented, it should be queried. To clarify-they are great questions-ie; pt transfused with a drop in h/h post op without documentation of the diagnosis.
    We (CDI dept) prefer to handle all queries to the physician's as we have noted a better response time and it streamlines the process.
    While I fully support and respect the Coders passion for accuracy to tell the whole story in the medical record, I struggle with the idea that every post discharge review can pull the CDI reviewer away from the concurrent realm.
    Not to stray to far from the topic-but does CDI own this part of the process for ensuring specificity at your organizations? Thoughts?
    Thanks,
    Kerry

    Kerry Seekircher, RN, CCDS, CDIP
    Documentation Specialist Supervisor
    Northern Westchester Hospital
    400 East Main Street
    Mount Kisco, NY 10549
    Email: kseekircher@nwhc.net
    Phone: 914-666-1243
    Fax: 914-666-1013

  • Kerry:

    At our site, the CDI team performs 'mostly ' concurrent queries. There are some exceptions - example - since we are in the Quality Team, we will perform retrospective review for HAC, Core Measures, ROM, etc. If needed, we will issue a post discharge query for such cases.

    Other queries are handled by coding - part of this is due to the fact the CDI team is vastly understaffed. We prefer to work with 'live' charts as we feel it is easier to get a response prior to discharge.

    Paul Evans, RHIA, CCS, CCS-P, CCDS
  • Another though- re: If we have unspecified DM going out into the coded data world, how does that help research for the little 10 year old with Type 1? It won't.

    If the condition does not meet the UHDDS definition of a reportable diagnosis it will not appear on the coding summary. So it won't go out into the coded data world. It will be in the chart, but it is my understanding other reporting entities use the coding summary and that is why we want 428.0 CHF (if supported by the documentation in the record) to be assigned the more specific code of 428.21 Acute Systolic CHF.

    Charlie
  • Hey, Paul -

    Just wondered how your facility's query position is morphing relative to the future implications of assigning NOS or unspecified ICD-10 codes?

    I did a little research and found that all of the major commercial payers (BC/BS, Cigna, Aetna, Humana) have posted information that they anticipate revising their policy and benefit rules to leverage the greater specificity available under ICD-10 (in other words, nonspecific codes = lower payment or none at all).

    I Googled "Impact of ICD-10 on healthcare benefits" and moved on from there. The information was eye-opening.
  • Katy,

    I politely (really!) have to disagree that we should focus on reviewing more records with "focused" queries.

    Most CDI programs somehow measure the # of charts reviewed out of the # assigned for review (% of cases reviewed). Say you review 100 records. If the overall query rate is 25% for all cases reviewed, your potential impact for all of that work is potentially 25%. If you query response rate is 85%, then your actual realized impact for all of that work is only around 21%. Doesn't sound too good, does it?

    Wouldn't it be better to data mine, identify which cases have the greatest likelihood of impact and focus your reviews on these cases? (Certain admitting diagnoses, certain MDs, certain procedures)?

    Of course, how we measure "impact" must be defined, too: DRG? SOI/ROM?, I-10 specificity? These are big questions, but I think that in order for a CDI program's impact to be truly reported, we need answers to these questions from our leadership. With I-10 approaching, suddenly how we're measured becomes a critical issue.

    Would love to hear your thoughts on this :-)
  • ____________Hi, (This is Paul from my pad) In truth, we have only 2.9 FTEE to perform ALL cdi reviews, so, it would not be possible for us to review every/all cases, we review samples, and include all payers. So, our current practice really won't change as we have no resources to review even more cases, such as those payers that state they will not pay for NOS codes. But, do you have links you could share as I would like to so research.

    I am not even sure it is 'legal to state this as a stance since use of NOS is not contradicted by the Official Guidelines, which is what we are all required to follow - coders, cdi, B/C and so on. Consider how many cases of 486 - Pneumonia, are reported very year or 'acute stroke' w/o further specification. I

    thanks..paul
  • edited April 2016
    Of course I agree that it is best to focus in on charts that the potential for impact is higher. But I still think that even with that, most CDI programs are unable to optimize their impact because of staffing. Obviously I recognize that each program is different. You have to weigh your resources, your hospitals expectations out of the program, physician buy-in, etc to determine what the best approach is for an individual program.
    I will admit that our program is pretty visible to Senior management and they have a say in what we do. Of course everyone would love to see perfectly complete records with the maximal specificity regardless of diagnoses, but when we talk 'results' with senior management and get feedback as to where they want our efforts directed, it is not simply to overall specificity. They want a targeted approach. This doesn’t always come down to $$. We are housed under quality so we have many things we focus on that may not directly impact dollars. But we are expected to show some sort of impact of our work. This may be; better patient care, improved quality metrics, financial, etc. There is always going to be variety among CDI programs because the longer you work in this field (at least in my very limited experience) the more areas you see in which a concurrent reviewer could be helpful to the hospital. It's virtually impossible to be engaged in all areas so where a program chooses to focus will likely depend on the desire of management.
    We talk a lot about physician impact and the reality is that physicians are under A LOT of pressure regarding documentation currently. It's not just coding/CDI. They are also trying to meet the expectations of UR, ID, Quality, Insurance companies, their cohorts, etc. I think it's important to be understanding of these issues and recognize that all these demands ultimately impact our physicians AND our patients. There has to be balance to any approach but where exactly that is will vary significantly depending on a variety of factors.
    My point is, queries take time. So if we are sending queries for all I-9 specificity available (which I seriously doubt programs are really doing), that is time that takes a CDI away from other important tasks too. This time may be better utilized reviewing a couple extra records a day, preparing some education materials, working with ID or quality to improve specific documentation, help develop new note templates, etc.


    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

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