Retrospective Query response - inappropriate
During a retrospective audit, our auditor identified an inappropriate query where there were not enough clinical indicators present on chart. The physician responded with a diagnosis that was not supported. The response is part of the legal health record and if rebilled will most likely end in denial.
Question: Do you notify the coder and ask for rebill? Do you decide not to send notification to rebill as it was not appropriate?
Comments
I would not bill the claim with the unsupported code. If I am understanding the question, the case was billed with a code that is not supported: if this is the case, I would definitely rebill it without that code assigned to the claim.
If it has not been rebilled with the inappropriate code, then CDI should notify the Coding Department of the issue, make a formal entry into the business record of the issue as to the specifics and do not rebill.
P. Evans, RHIA, CCDS
I'm a little confused here...If the physician responded to the query, I would think that the diagnosis the physician responded with would need to be coded regardless of clinical indicators, or there would need to be a another query right?
How do you justify not billing a code that was documented, especially on a query, unless it doesn't meet UHDDS?
Maybe the OP could clarify the situation?
The question states the ‘query was inappropriate’ because it lacked clinical indicators, and this resulted in the MD ‘agreeing’ with the query. If the query lacked clinical support, it is not compliant.
If there would be any doubt as to how to proceed, my suggestion is that one consult with facility Compliance and Legal Team.
However, I can state without reservation that I would not advocate coding this code as it was charted as the result of a query that is not compliant.
P. Evans, RHIA, CCDS
The original post says "there were not enough clinical indicators present on the chart". I would question what "enough" means as the compliant query brief states there is a not a specific number required to query.
It also says the physician responded "with a diagnosis that was not supported", not that they agreed with the query, so again I think some clarification might be needed here.
If at least one relevant clinical indicator was given on the query and it was not leading, I don't think an auditor should decide that the diagnosis is likely to be denied and therefore shouldn't be coded. Maybe I'm misunderstanding the situation, very difficult over text like this, but that doesn't seem right.
The question states it is an ‘inappropriate query lacking clinical indicators’. Taking this statement verbatim, the query is leading. The Brief does not tell us ‘how many indicators’ are required, but the original poster seems to clearly agree this particular query lacks clinical support. My response is based on this statement.
Yeah I guess it would be good to hear from OP again, as the feeling I get from the post is that the CDI queried based on a subset of indicators and the physician confirmed the diagnosis, but the auditor has arbitrarily decided there weren't "enough" indicators to validate the diagnosis so they are recommending to remove the code.
So let us know OP!
Thanks.
My CDI auditor indicated a query was not needed on this chart. In reviewing the chart, there was not supporting documentation to justify the query. However, the physician responded and agreed to the diagnosis.
I think you would need to code the diagnosis since it was documented and prepare for a denial if one comes on that code and accept it. It is documented so must be coded. Learning opportunity for the CDI, in my opinion.