Post-disharge queries
Hello all,
I am looking for some guidance regarding post-discharge queries. Our facility is having a discussion about whether the provider needs to make a changes (ie-addendum) to the discharge summary to incorporate the query answer. Our queries are a permanent part of the medical record and are either electronically in the record or are printed for the provider to sign and scanned in to the record.
This recently came about due to some post-bill queries that made upward DRG changes that were denied upon resubmission because the only place the additional diagnosis was documented was on the query. Now, our facility is discussing whether to make all providers go back after discharge to add the diagnosis in their discharge summary as well as answering the query. I should also note, that our post discharge queries have a statement noting that they are addendums to the record, usually specifying the discharge summary and date.
I realize that it would be best to have the query diagnoses documented more than on the query form, but if we are unable to review a chart concurrently, the query is not placed until after discharge, or the provider doesn't answer the query before discharge, then the only documentation we have is on the query form. If we truly must have them change the record, this will take a major initiative in our organization to do this.
Are there any specific guidelines or rules outlining this issue that you call could share with me? How do you handle situations such as these?
Thank you,
Janine Podany, MSN, RN
Kearney Regional Medical Center
308-865-3908
I am looking for some guidance regarding post-discharge queries. Our facility is having a discussion about whether the provider needs to make a changes (ie-addendum) to the discharge summary to incorporate the query answer. Our queries are a permanent part of the medical record and are either electronically in the record or are printed for the provider to sign and scanned in to the record.
This recently came about due to some post-bill queries that made upward DRG changes that were denied upon resubmission because the only place the additional diagnosis was documented was on the query. Now, our facility is discussing whether to make all providers go back after discharge to add the diagnosis in their discharge summary as well as answering the query. I should also note, that our post discharge queries have a statement noting that they are addendums to the record, usually specifying the discharge summary and date.
I realize that it would be best to have the query diagnoses documented more than on the query form, but if we are unable to review a chart concurrently, the query is not placed until after discharge, or the provider doesn't answer the query before discharge, then the only documentation we have is on the query form. If we truly must have them change the record, this will take a major initiative in our organization to do this.
Are there any specific guidelines or rules outlining this issue that you call could share with me? How do you handle situations such as these?
Thank you,
Janine Podany, MSN, RN
Kearney Regional Medical Center
308-865-3908
Comments
Brief response. It depends upon your local by-laws. There is nothing I am aware of in cited authoritative source deeming that the query response must be in the summary. Some 3rd parties insist all diagnoses be 'in the summary'; while this is desirable, again, there are actual references in Coding Clinic stating we use the entire record to assign codes. An issue of Coding Clinic provides an example in which only the ED MD records acute respiratory failure, and the advice is this is coded unless there is further dissonance charted.
Paul Evans, RHIA
Our queries are part of the permanent medical record. We do not currently require the provider to make an addendum to the DC Summary to include the query response.
I am interested to see what others have to say about this question.
Jeanne McCorkle BSN, RN, CCDS