Who to query...
We are getting pressure from our othopods to send all queries to their NP. Our bylaws allow NP's to function independently and they are allowed to answer queries without co-signature. We routinely send queries to NP's who are caring for patients and we have great success with them. The difference here is that the orthopods want us to send ALL queries to their NP, even if she is not caring for the patient (she does not see all patients). I have told them that AHIMA guides us to query the provider that documented whatever needs clarification (though because we have a team approach with hospitalists, we often are querying the attending caring for the patient now, not necessarily the documenting provider) and that I do not think this is appropriate. Coding has said they will not accept queries from a non-treating provider (which I agree with)
Now they are suggesting that we query the NP even if she has not yet seen the patient but that she will then see any patient we send a query on prior to answering. I still don't like it.
What do you think? Anything you know of that I can use to defend my position?
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
Now they are suggesting that we query the NP even if she has not yet seen the patient but that she will then see any patient we send a query on prior to answering. I still don't like it.
What do you think? Anything you know of that I can use to defend my position?
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
Reference: AHIMA, Managing An Effective Query Process
Who to Query
A healthcare entity's query policy should address the question of who to query. The query is directed to the provider who originated the progress note or other report in question. This could include the attending physician, consulting physician, or the surgeon. In most cases, a query for abnormal test results would be directed to the attending physician.
Documentation from providers involved in the care and treatment of the patient is appropriate for code assignment; however, a query may be necessary if the documentation conflicts with that of another provider. If such a conflict exists, the attending physician is queried for clarification, as that provider is ultimately responsible for the final diagnosis.
There are similar thoughts expressed in issues of Coding Clinic whereby we are precluded from coding directly from Pathology Reports as the pathologist (or radiologist, for that matter), while a clinician, is not actively assessing the patient, performing examinations, reviewing all labs, etc.
I also imagine the Medical Staff By Laws stated clearly exactly 'who' is authorized to act as a clinician in order to 'render a diagnosis' per licensure.
So, clearly, it is not appropriate to query a PA, NP, MD, if they are not on the active treatment team.
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: 415.412.9421
evanspx@sutterhealth.org
NP/PA to do the "dirty work". There are varying opinions on this:
1. NP will become very good at documentation and may be your best
friend
2. Queries will get answered timely
3. If they are going to respond to queries they must see the
patient. If not, they are a potential liability for the medical group
and hospital.
I also wanted to respond to the group regarding who/where you can obtain
documentation from:
Pathology = no
Echo = no
Radiologist = no (however, CDI/coding can pull the specific fracture
site and/or vessel sites directly from reports as long as the diagnosis
is stated in the H & P/PN/Consult/ER, etc.
EKG = no
Cath report = yes
However, remember that in a query you can "refer" to that information.
Deanne Wilk, BSN, RN, CCS
CDI Manager
Good Samaritan Health System
4th & Walnut Streets
PO Box 1281
Lebanon, PA 17042
Desk: 717-270-4804
Mobile work: 717-679-7926
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: 415.412.9421
evanspx@sutterhealth.org
Deb
Debra Stewart, RN, BSN,
Clinical Documentation Specialist
Halifax Regional Health System
2204 Wilborn Avenue
South Boston, Va. 24592
(W) 434-517-3317
(C) 434-222-9884
Debra.stewart@halifaxregional.com
Thanks everyone!
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
Sorry to bring this back up but it’s not going away. I am trying to stand my ground that queries must go to attending/documenting MD’s but I am looking for additional arguments beyond just our piece. If a query was answered by an NP not seeing the patient prior what should coding do with it? How would your coding department view this and are there any references that would guide this decision?
If I was our coding manager I would not want to code off such a query, but what could I use to back this up?
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
There is a coding clinic that should help, First Quarter 2004. ... Medical record documentation from any physician involved in the care and treatment of the patient, including documentation by consulting physicians, is appropriate for the basis of code assignment. I can't italicize, highlight or underline apparently-new email formatting, but what I wanted to emphasize was the involvement in the treatment and care. There is a more current coding clinic for this from March 2014 for ICD-10, thus demonstrating that this rule remains important.
Thanks,
Kathy
Kathy Shumpert, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Community Howard Regional Health
3500 S Lafountain
PO Box 9011
Kokomo, IN 46902
O 765.864.8754 | C 765.431.0123 | F 765.453.8447 | E kshumper@communityhoward.org
This is helpful. Looking at this, I think what I really need is a definition of 'involved in care and treatment'. Our ortho team would say that their NP is involved in the care of all their patients even if she has never physically seen the patient or never documented on the patient charts. She is a part of their 'care team'. My suggestion would be that we need to have evidence in the record that she is involved in the care of the patient however I don’t see this explicitly stated anywhere...
Thanks again!
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
AHIMA states - below:
Documentation from providers involved in the care and treatment of the patient is appropriate for code assignment;
AHIMA
Managing an Effective Query Process
I provide them with education that the query should be only be answered by the participating team members.
Lisa
Lisa Romanello, RN,BSN,FNS,CCDS
Manager, Clinical Documentation Improvement
Quality and Compliance
CJW Medical Center
Office phone: 804-228-6527
Cell phone: 804-629-0396
AHIMA Approved ICD-10 CM/PCS Trainer
Angelisa.Romanello@HCAHealthcare.com
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
Interestingly enough, our ortho docs have NPs and PAs however they are not allowed to answer queries per our by-laws. We can only query if they are employed by our hospitalist group since they are employees of the hospital.
It is a tough situation. Good Luck
Lisa
Anecdotally, I recall a corporate integrity agreement whereby an MD working as a CDI documented 'sepsis' in cases for patients he never saw with the belief this was acceptable due to his education...CMS fined the client heavily stated the MD 'never examined the patient".
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: 415.412.9421
evanspx@sutterhealth.org