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

Comments

  • We are not allowed to query a clinician that is 'not actively involved in the care of the patient'.

    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

  • edited April 2016
    I have seen this happen at a number of facilities. They are using the
    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

  • Precisely stated, Deanne

    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

  • Yes Just like Deanne stated is what we use!

    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



  • I support queries going to the provider caring for the patient. This is often the NP in certain service lines (trauma is a big one here). But where I am drawing the line is at sending the query to an NP if they have not seen the patient. I gave them the same portion of the query brief that you C&P Paul :). Work around, work around, work around....

    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

  • Hi all,
    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
  • edited April 2016
    Hi Katy,
    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

  • Thanks Kathy,
    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


  • I do not believe that any clinician (NP, PA, MD) may (or should) answer a query unless they are 'DIRECTLY' involved in the care of the patient. Medical Staff By-Laws typically define this as something such as 'a person that is performing physical examination of the patient and reviewing laboratory and radiology results' in order to document a diagnosis as per licensure". I am paraphrasing. By-Laws typically and specifically address precisely who may document in a patient' record and also define who may render a legal diagnosis.

    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


  • edited April 2016
    I agree. Our by-laws allows for NPs and PAs to be sent queries however they must be on the care team. From time-to-time I have had providers say to me that their partner is out of town or off so just send the query to me.
    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





  • I completely agree with both you and Paul. The ortho team is maintaining that the NP is a member of the 'care team' on every case.....

    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
    Katy,
    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

  • I believe your best recourse would be to check your By-Laws and refer them to their own Med Staff Regs..


    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





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