Query Response

laura.mancinilaura.mancini
in CDI Talk Archive
Some of our physicians have responded to our concurrent queries that are part of the permanent medical record by circling the diagnosis they feel applicable, signing and dating the actual query. This is left in the medical record but our coders are not accepting this documentation for coding. In some cases they are initiating another coding query after discharge re to the same diagnosis that the MD already addressed. A Regs consultant was questioned on this practice and per the consultant the guidance received was that circling cannot be accepted because it cannot be validated that the document was done by the physician. I could understand this reasoning if the physician didn't sign and date the document but with his signature/date...how is this any different than the MD "checking" level of care or for that matter "checking" standard order sets w/signature and date?

Does anyone else have this issue/problem and if so did you resolve it?

Thanks!

Comments

  • bosankorbosankor
    edited May 2016
    Is anyone using Soarian or have any feedback on how it would compare to Allscripts?

    Roberta Bosanko MS, CDIP, CCS-P, CPMA, CPC-P, CEMC
    AHIMA ICD-10-CM/PCS Training Instructor
    Director, Finance ICD-10
    Hospital For Special Surgery
    535 E 70th Street
    New York, NY 10021
    bosankor@hss.edu
    212-774-2906 Office


  • ddraizeddraize
    edited May 2016
    I have one query for diagnosis as none on chart response "SICK"

    Diane Draize RN, CPUR,CCDS
    Clinical Documentation Specialist

    Ministry Door County Medical Center
    diane.draize@ministryhealth.org
    920-743-5566 ex 3143

    We earn trust by working together as One Ministry to keep PATIENTS FIRST in everything we do






  • cmclose@saintfrancis.comcmclose@saintfrancis.com
    edited May 2016
    That is TOO funny Angie!!!

    The query responses here are a permanent part of the medical record so
    that kind of physician response (to query) would be very interesting in
    a lawsuit, audit, etc.!



    Claudine Hutchinson RN
    Clinical Documentation Improvement Specialist
    Children's Hospital at Saint Francis
    Email: chutchinson@saintfrancis.com
    Office: (918) 502-6603



  • cselukecseluke
    edited May 2016
    I have another one- Resident with hand upraised in "talk to the hand"
    position: "I'm SURGERY!"



    Cathy Seluke, RN, BSN, ACM, CCDS

    Supervisor Clinical Documentation Compliance

    MaineGeneral Medical Center

    Augusta and Waterville, Maine

    (207) 872-1796

    Cathy.Seluke@mainegeneral.org



  • laura.bohls@prairielakes.comlaura.bohls@prairielakes.com
    edited May 2016
    My favorite: Orthopedic surgeon told me to "ask the real doctor."

    Laura Bohls, RN CDS
    Prairie Lakes Healthcare System

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