Compliant query - practice brief
Hello,
I am interested in your thoughts on an issue with highlighting and bolding. We copy and paste lab values into queries as supporting evidence. For certain labs (critical values), we are unable to undo/remove the highlighting and they remain red within the copied information. Are any of you having this issue and what are your thoughts regarding the query being compliant. Thanks in advance.
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My understanding is that the underlining, bolding, Italics refers to anything in the query that could be considered "leading", ie: altered mental status due to METABOLIC ENCEPHALOPATHY; altered mental status due to delirium. It would be like highlighting the choice you want the physician to pick. You could always put quotations around the copied and pasted labs to denote it was taken directly from the record.
Thanks for your thoughts. I totally agree and to me lab values highlighted/red font in their original form from the record should not be considered leading but we are have to charge our process based on a recommendation from a consultant.
We use the snippet tool to paste in our queries in Meditech and note next to it "snapshot from Meditech" so the provider knows we didn't highlight. Our facility supports this and does not believe it be be non-compliant.
Agree with the above. We have been instructed not to underline, color, bold/italicize, etc. Apparently, we have even received denials due to "leading" based on the way we had spaced out our choices.