Unable to determine queries
Hi. I am the CDI supervisor for a large hospital in MS. We had a recent denial on a query for non-compliance from HUMANA. The patient met clinical indicators for acute respiratory failure. A query was sent to the attending (trauma surgeon) who answered with “unable to determine”. The CDI specialist then sent it to the pulmonologist who in turn answered “acute hypoxic resp failure”. Humana is stating that we kept searching until we got the answer we wanted. We disagree because the pulmonologist is a specialist in this field. She should have probably been asked initially but the CDI went with the attending. What are your thoughts on queries like this? Do you have any policies or procedures in regards to asking another Doc when one is “unable to determine”. Please advise. Thanks so much!
Comments
Our policy is that once we have a response on a particular query, we will not pose that particular question again during the encounter.
You could attempt to appeal with the fact that since the attending physician was unable to determine, you posed the question to the specialist who confirmed the diagnosis. It might be worth a shot.
Otherwise, for unable to determine query responses, we do not code the condition.
AHIMA Guidelines for Achieving a Compliant Query Practice (2019)
”it is considered non-compliant to continue asking the same query to the same or multiple providers until a desired response is received”.
P. Evans, RHIA, CCDS