Query Process Question...
This question is for those of you who are currently working with a Hybrid EMR (Paper on the floor EMR after discharge, whose CDI queries are NOT a part of the permanent Medical Record, and who uses either in-house or contracted employees to scan your records.
What is the process of returning your CDI queries to the appropriate CDS after discharge?
Our initial procedure was to have scanning/prepping:
>>remove the queries,
>>place them in a "CDI File",
>>the earliest Coder arrives and distributes to the rest of the Coders for the day
>>and when chart is coded they place the query with comments in the appropriate CDS box for reconciliation.
However, somewhere we've had a process break-down!
Now, we are looking at not giving the queries to the coders at all but returning them directly to the CDS. The thought process is when the coder codes the chart,if the documentation is there it will be coded.
We also keep a copy of the query for our own records (and in case the original becomes "lost").
Does anyone else NOT give their queries to your Coders? What kind of problems have you experienced?
Thank you in advance for your thoughts!!
NBrunson, RHIA, CCDS
What is the process of returning your CDI queries to the appropriate CDS after discharge?
Our initial procedure was to have scanning/prepping:
>>remove the queries,
>>place them in a "CDI File",
>>the earliest Coder arrives and distributes to the rest of the Coders for the day
>>and when chart is coded they place the query with comments in the appropriate CDS box for reconciliation.
However, somewhere we've had a process break-down!
Now, we are looking at not giving the queries to the coders at all but returning them directly to the CDS. The thought process is when the coder codes the chart,if the documentation is there it will be coded.
We also keep a copy of the query for our own records (and in case the original becomes "lost").
Does anyone else NOT give their queries to your Coders? What kind of problems have you experienced?
Thank you in advance for your thoughts!!
NBrunson, RHIA, CCDS
Comments
>>> CDI Talk 2/10/2011 10:34 AM >>>
This question is for those of you who are currently working with a Hybrid EMR (Paper on the floor EMR after discharge, whose CDI queries are NOT a part of the permanent Medical Record, and who uses either in-house or contracted employees to scan your records.
What is the process of returning your CDI queries to the appropriate CDS after discharge?
Our initial procedure was to have scanning/prepping:
>>remove the queries,
>>place them in a "CDI File",
>>the earliest Coder arrives and distributes to the rest of the Coders for the day
>>and when chart is coded they place the query with comments in the appropriate CDS box for reconciliation.
However, somewhere we've had a process break-down!
Now, we are looking at not giving the queries to the coders at all but returning them directly to the CDS. The thought process is when the coder codes the chart,if the documentation is there it will be coded.
We also keep a copy of the query for our own records (and in case the original becomes "lost").
Does anyone else NOT give their queries to your Coders? What kind of problems have you experienced?
Thank you in advance for your thoughts!!
NBrunson, RHIA, CCDS
NTB
Debbie S
scanners. So when they scan a record with one of our queries in it,
they remove it from the record and give it to us. Our queries do not
get scanned and are not a part of the permanent record.
Greta Goodman
Clinical Documentation Improvement Specialist
Health Information Management
Virginia Hospital Center
1701 North George Mason Drive
Arlington, VA 22205
703-558-5336
ggoodman@virginiahospitalcenter.com
NTB
If I query for the clarification of a diagnosis and realize that even though my clarification was answered it was not coded, I can contact the coding manager and tell her where in the chart the diagnosis can be found. If there was a coding error she has the coder change or add the code and the chart is rebilled.
This works well, but it would be nice if the coders could see our query forms, then they could be on the look out for a response. Before we transitioned to an EHR our queries were scanned along with the rest of the chart and the coders (who work remotely) could see them. However, now with our EHR all scanned documents are considered part of the medical record so we no longer scan our queries.
Greta Goodman
Virginia Hospital Center
medical record. To resolve the communication with coding, I sent an
email every day with a list of which patient received a query, what the
query was, and the interaction I had with the provider. I will then
send updates with the provider's response (if any) so they can track it
through and follow up if needed.
It works well here and keeps us in touch with what the other is doing.
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
the progress notes, we remove the query. Our facility uses ChartMaxx
for the EHR, when the dismissed chart is scanned into ChartMaxx we place
an electronic note on the appropriate patient's chart and the coder then
will know that there was a query. If a discrepancy is noted, or the
coder can not find the response, we discuss.
Michelle Clyne, RN, BS
Clinical Documentation Improvement Specialist
This way, the worksheet is directly available to the coders.
The paper sheets are not returned to the CDI, as we can recall from archives in the CDI software as well as from the scanned record.
From our experiences as well as from many of the other comments, sometimes the easiest hurdle to achieve are the technical ones, followed by the general process. Hardest are the individual behaviors -- do the coders reference the sheets, provide feedback, how are discrepancies resolved & how strong is the collaboration between those working concurrently and those working post-discharge.
Don