Coding queries that are not considered part of legal medical record

jackietouch@aol.com

Couple of quick questions for those working in facilities where queries/clarifications are not considered part of the legal medical record.

Can and do your coders code from queries/clarifications if it is the only documentation of a diagnosis? For example, concurrent clarifications/queries that are responded to after patient has been discharged so not documented in body of the encounter.

If so, how is this addressed in the event of an audit or request from insurance for medical records?

Thanks in advance for your feedback!
Jackie Touch

dariceg

The best place for documentation is as a part of the legal health record - as an addendum note, properly authenticated and dated.   If the query form itself is typically not kept as part of the record, but the physician had added 'original' documentation that is used in coding, one of two things needs to occur: a) the clinician must be instructed to document the same information into the record, or b) the query then must become a part of the record (it can be scanned in as an addendum document.)  As a best practice - any query documents should clearly state instruction for the clinicians to document any changes directly into the record, and not respond on the query form itself unless the form is intended to be kept permanently.   Darice Grzybowski, MA, RHIA, FAHIMA

ssavinsk@valleyhealthlink.com

I have the same question as above.
We do not use our query as permanent part of medical record.
How do you handle the query response if it is entered only on the query itself?
thank you.
sharon

don.cdi.rn@gmail.com

When our CDI queries were not part of the legal medical record, only documentation on a note, etc. was used for coding and the CDI would need to follow up with the provider requesting an additional PN or an addendum. Our coding queries had been part of the record for quite some time.

For a number of years now, CDI queries are also part of the record.

Queries are part of the record whether or not the provider answers as well as however they may answer.

Don

jackietouch@aol.com

ssavinsk@valleyhealthlink.com said:

I have the same question as above.
We do not use our query as permanent part of medical record.
How do you handle the query response if it is entered only on the query itself?
thank you.
sharon

Our coders issue a post-discharge query which then becomes part of the legal medical record.

Jackie