Provider Query Response

joan.rucker@va.gov

We have a situation where the Coders/CDS sent a query to a provider/attending who wrote the progress note for clarification of diagnosis. Coder/CDS enters the query information in Provider Query Tracking (PQT) System.

Provider/attending staff write back and state he is not responsible for the record or he is not familiar enough with the patient condition to provide clarification.  The coder, then send the same query to another provider/attending for clarification who also saw the patient during the admission who may provide clarification.

 Question :  Should the initial query be deleted due to the provider response or should we maintain the query in PQT and add Impact Status of “other” and document the provider response in comments? Then add a second query in PQT for the second provider. 

Appreciate your input.

Joan

evanspx@sutterhealth.org

Neither query should be removed as both are legal and formal elements of the medical record.   Further, I would definitely ensure to retain the first, (Attending’s) response as this provides insight as to why a second query was issued.  I am confused as there can only be one Attending, and your message seems to mention there are two attendings which is not possible.  

P. Evans, RHIA, CCDS

This can be a complicated topic, and CDI policy and procedure should describe the duties of the Attending regarding a duty to respond to a query.  There are times a query can be sent to another provider other than the Attending, but if there is ‘dissonance’ charted, the Attending has the final say.  This should be covered in your formal P&P.    

You may wish to have a conversation with HIM/Compliance regarding how or when original medical records may be closed or altered, modified or redirected, as they are not to be deleted.  

The 2020 Pocket Guide by Pinson/Tang has a nice section regarding whom to query, when and why.  It is hard to convey something this complicated in this forum completely.

joan.rucker@va.gov

Thanks Paul for your response.

i did not think of the legal implication by deleting a query. Yes, there should be only one attending.  However, I am at VA Medical Center and our patient population do not have have a consistent attending physician.  An attending can be on for 3 days during the admission and on day 4 of the admission there is a new attending...this occur throughout the entire admission episode.  For instance, today we query Attending A because he the provider for xdays and three to four days later Attending B is the provider.To further complicate the issue, by the discharge there is a different provider.

Joan Rucker, RHIT, CDIP

evanspx@sutterhealth.org

Thanks for the f/u..I get it, now, about the Attending issue. Same here as we have Teams that follow the patient.  I’d keep the original query as it demonstrates the need to issue the 2nd for the same topic.

Paul