Our physician query process is part of the electronic medical record (electronic queries). If the physician documents on the query form, can the documented response be coded?
I'd recommend this be discussed with your Compliance Team, CDI leaders and HIM leaders. The query policy should be vetted and it should detail precisely who may issue a query, when, why, and how it is recorded. The policy should also address whether the query is or is not a permanent part of the chart. IMO, if the query is retained in the record, and Best Practice is observed, the response on the query form should be coded - it IS a permanent part of the record. There can always be exceptions to this and special circumstances.
We utilize the queries for coding. However, you have to watch it. We have gotten some denials for lack of "clear and consistent documentation" from the payers when they are only documented on the queries. We have been doing a big education push regarding the importance of clear and consistent documentation throughout the medical record.
Our hospital does the same as Erica and we have also had denials for the same reasons she mentioned. We are a teaching hospital and some days it is a challenge to get the residents/medical students to pull that diagnosis out of the query and include it in the progress notes.
Certainly agree that any condition coded must be supported with proper context and clinical support..regardless of the source document..query, note, consult, op report.
Comments
I'd recommend this be discussed with your Compliance Team, CDI leaders and HIM leaders. The query policy should be vetted and it should detail precisely who may issue a query, when, why, and how it is recorded. The policy should also address whether the query is or is not a permanent part of the chart. IMO, if the query is retained in the record, and Best Practice is observed, the response on the query form should be coded - it IS a permanent part of the record. There can always be exceptions to this and special circumstances.
P. Evans, RHIA, CCDS