Queries as Discrepancies

dbutlerdbutler
edited May 2016 in CDI Talk Archive
How many folks do or do not count unanswered queries as a chart discrepancy?
Is there a difference between concurrent or post-discharge queries?

Thanks,
Don

Donald A. Butler, RN, BSN
Manager, Clinical Documentation
PCMH, Greenville NC
dbutler@pcmh.com

Comments

  • lisa.schuellisa.schuel
    I will be out of the office until Tuesday, October 11th. I will respond
    to your email when I return. Thank you.
  • kimberly.strandkimberly.strand
    edited May 2016
    Don, In our organization only Retro queries placed by Coders or CDS's get tagged as a deficiency. Unanswered CDS concurrent queries are called, "pended" and are resubmitted as "retro" queries. So I guess in the end if MD does not answer it gets tagged as a deficiency.

    Kimberly
  • paxnerospaxneros
    edited May 2016
    We have similar procedure w/post discharge queries issued by coders. However, if the CDS query is unanswered on discharge it is not tagged as a deficiency unless the info. Is still needed as an MCC or CC. At the point the coder will continue the query and a deficiency is entered.

    NBrunson, RHIA, CCDS
  • catladyrncatladyrn
    Per our hospital's medical staff by-laws, we are not allowed to count unanswered queries, either by us or by coding, as discrepancies. We do track CDS unanswered queries and a mechanism is being developed to track coder unanswered queries as well.

    Renee


    Linda Renee Brown, RN, CCRN, CCDS
    Certified Clinical Documentation Specialist
    Banner Good Samaritan Medical Center
  • fishdl@shands.ufl.edufishdl@shands.ufl.edu
    edited May 2016
    Since going live with our EHR in May, chart deficiencies are created and tracked for all of our queries - both concurrent & retrospective. BTW, the CDI Team now creates ALL queries and deficiencies.
    Thanks.

    Donna Fisher, CCS, CCDS
    Clinical Documentation Improvement Coordinator
    Health Information Management
    Shands at the University of Florida
    352-265-0680 Ext 48769
    fishdl@shands.ufl.edu
  • dallend@einstein.edudallend@einstein.edu
    edited May 2016
    Post discharge queries are processed as deficiencies. These include coder requested and CDI initiated post discharge queries. CDI processes all post discharge queries. If a post discharge query is over 2 weeks old with no response the resident/physician is fined until he/she responds.
  • robert.hodges2robert.hodges2
    edited May 2016
    Our queries are not part of the medical record and are therefore not considered discrepancies. However all abandoned queries are reported to the Chief of Staff and the medical record review committee on a monthly basis.



    Robert


    Robert S. Hodges, BSN, MSN, RN, CCDS
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov

    "We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley
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