non compliant physician query identified questions

andiet@hotmail.com

During a final pre-bill coding review, the coding leader identifies a CDI initiated query that is does not meet AHIMA guidelines for a compliant query. However, the physician has responded to the query with a diagnosis which is then utilized in the coding process. The response by the physician is noted only in the query and not in the progress notes.

 

What steps should the coding leaders take after the non-compliant query is identified? Education would definitely be given to the coder. But does the query stay in the medical record?  Should another query be sent out with an explanation of the reason for the duplicate query? What do we do with the diagnosis that the physician has noted on the query?

evanspx@sutterhealth.org

Great question:  If it were I, I'd consult with Compliance and respond accordingly.  Several things occur to me,  You stated that 'education should be given to the coder".  So, I assume you must mean the coder should be directed to recognize a query that is not compliant and refer it to management rather than coding the condition?  I also assume education will be provided to the CDI initiating the query that is not compliant?

  As far as remaining in the record,  Compliance  needs to be consulted.  But,  I'd would certainly remove the code assigned as a result of the query; universally, I've been taught that one never alters or destroys any portion(s) of a record.  My instinct would be to leave it in the record as it was initiated and the MD has responded.  I'd not be comfortable removing the note.

I'd make an entry in the 'administrative portion' of the chart (there is such an element) and would make note the condition was noted on a query, but not coded.  I would personally take my loss, learn, and not query again for the same condition given that my decision would be to have the original note remain in the record.

All HIM departments have a policy and procedure regarding 'correction and edits' to existing charts, and they 'should' be consulted on this issue given HIM is responsible for content of medical records  and serves as the Custodian of records for legal purposes.   I am citing to you standard steps I have used when working as an HIM Director.

Looking forward to other responses.

Paul Evans, RHIA, CCDS

andiet@hotmail.com

Yes to both your questions and THANK YOU! You have been a great help.

izusman

What is your organizational policy? Do queries become a part of the legal medical record? Is it a common practice to provide an answer on the query form only? This scenario is somewhat like a Catch 22.If this case gets audited, the code for this condition will be denied in both situations:

• If the query is not released a a part of LMR, there is no documentation supporting the code
• If the query is released, the code still will be denied since the query was non-coompliant

I agree with Paul that the formal process should be outlined in discussion with HIM and Compliance, but until it is done, I wouldn't take any steps for chart correction. So I would prefer to lose on this particular case and wouldn't assign a code for the queried condition, but would use this as an educational opportunity for both coders and CDI specialists.

Irina Zusman

afrady@blr.com

So many hospitals use the query as a permanent part of their medical record and will accept diagnoses which are ONLY written on the query.  I have never been comfortable with this practice and have always recommended that the physician add (if appropriate) the diagnosis to his regular progress notes and the discharge summary. If the query is non-compliant, i would then move it to the administrative record and use it as an opportunity for education.  If the query is the only place documentation occurs I think you are at risk some what even if the query IS compliant.  That is of course, just my opinion.  However if the query is non-compliant and this is the only place the documentation occurs, i have to agree with Paul above. 

Keep in mind that auditors now have a mandate to start looking to see if a query is compliant and take action when it is not.  Also keep in mind that many payers actually require as part of their normal review process that a diagnosis be listed more than once in a chart, and they take extra special offense when that one place is just on a query form.  Even I have to admit that seems a bit "sketchy" if it is a regular practice, although it CAN legitimately happen once in a while of course.