Denial due to query examples
We are seeing denials due to query examples provided. Our queries are a part of the permanent medical record. We have an payer that denied the diagnosis because according to the payer "The multiple choice query format did not include and option for clinically undetermined, as directed by AHIMA guidelines for Achieving a Compliant Query."
Referencing the following from the practice brief:
Multiple choice query formats should also include additional options such as “clinically undetermined” and “other” that would allow the provider to add free text.
The query included other as an example but the payer is stating you have to include clinically undetermined and other for the query to be compliant. I have always read this statement as multiple choice query format must include an out or an option for the provider to add free text for example other and clinically undetermined.
My questions is must you have both other and clinically undetermined as an example for the query to be compliant according to the AHIMA Guidelines for Achieving a Compliant Query?
Referencing the following from the practice brief:
Multiple choice query formats should also include additional options such as “clinically undetermined” and “other” that would allow the provider to add free text.
The query included other as an example but the payer is stating you have to include clinically undetermined and other for the query to be compliant. I have always read this statement as multiple choice query format must include an out or an option for the provider to add free text for example other and clinically undetermined.
My questions is must you have both other and clinically undetermined as an example for the query to be compliant according to the AHIMA Guidelines for Achieving a Compliant Query?
Tagged:
Comments
I interpret the Guidelines to state that a query should include "Other" and "Unable to Determine" as responses. In my view, Unable to Determine and Clinically Unable to Determine have the same intent and meaning.
Paul Evans, RHIA, CCDS
Paul, I'm going to have to look that word up, but I am sure I totally agree with you.
Yes, I do agree.
I would say that it's better and best practice to include the options of Unable to Determine and Other to safeguard your queries from such insurance practices and increased scrutiny from external audits or reviewers. We definitely include those options in our query practice. I have even established query expectations to include a non-impacting option when asking for an impacting option. We had a denial for encephalopathy, which stated that we did not provide the physician with an alternative option for "altered mental status". I must agree with the payer here (and have educated my staff to always include such alternative options). With the increased scrutiny and eyes into CDI departments, I would advise implementing a very strong and (overly) credible query practice. When you clarifications are very solid and credible with multiple options, there is little room for scrutiny or denial. Strong query practice essentially mitigates denials, which is also an advantage or benefit to having a CDI Dept.
Thanks for everyone's input! I do feel like leaving the unable to determine example on the query is an easy denial prevention strategy. It is already included on all of our query templates so I updated and educated my CDI. I agree a strong and credible query practice is very important with the increase scrutiny from external audits.
Referencing the following from the practice brief:
Multiple choice query formats should also include additional options such as “clinically undetermined” and “other” that would allow the provider to add free text.
The query included other as an example but the payer is stating you have to include clinically undetermined and other for the query to be compliant. I have always read this statement as multiple choice query format must include an out or an option for the provider to add free text for example other and clinically undetermined.
My questions is must you have both other and clinically undetermined as an example for the query to be compliant according to the AHIMA Guidelines for Achieving a Compliant Query?
I recently wrote a very lengthy appeal to a payer regarding denial with a claim that our query did not follow the standards of practice according the AHIMA Guidelines for Achieving a Compliant Query Practice. I recommend reading, very carefully, redlining the AHIMA Practice Brief and paying special attention to words such as "and, or...should include, may include". These words provide guidance on the intent of the document.
The AHIMA Practice Brief (2016 Update) states: "Multiple choice query formats should include clinically significant and reasonable options as supported by clinical indicators in the health record, recognizing that there may be only one reasonable option. As such, providing a new diagnosis as an option in a multiple choice list-as supported and substantiated by referenced clinical indicators from the health record-is not introducing new information. Multiple choice query formats should also include additional options such as “clinically undetermined” and “other” that would allow the provider to add free text. Additional options such as “not clinically significant” and “integral to” may be included on the query form if appropriate."
I interpret this to mean that all multiple-choice queries should include BOTH options of "Other" and "clinically undetermined" (can be worded "unable to determine" or "clinically unable to determine"). Including both options provides a stronger argument when appealing the denial.
It's similar to interpreting law and policies... A comma or semicolon makes a world of difference in interpretation and compliance.
I hope this helps!
Angelica Naylor