RAC and Queries that are not a permanent part of MR

sharon.colesharon.cole
edited May 2016 in CDI Talk Archive
We’ve just now gotten our first big RAC audit and they specifically requested queries. Our queries (CDI and coding) are not a permanent part of the medical record. We are pulling ours to submit, but the Coding Supervisor says since the queries are not a permanent part of the medical record, she is not going to submit the queries written by the coders. My question is, how will this affect the audit?
Thanks in advance for any advice!

Sharon Cole, RN, CCDS
CDI Specialist Team Leader
Providence Health Center
254.751.4256
Sharon.cole@phn-waco.org

Comments

  • paxnerospaxneros
    edited May 2016
    That's scary!

    Is the RAC asking for queries that are a part of the medical record or for your non-permanent queries?

    I would think that unless ypur queries are part of the record you wouldn't need to provide the copies of your non-permanent queries.

    Are they paper copies or have they been scanned to a business area of the chart?

    Thanks,

    Norma T.Brunson, RHIA,CDIP,CCS,CCDS

  • sharon.colesharon.cole
    edited May 2016
    Norma,
    First of all, we have a hybrid record, so the queries are paper and are not a permanent part of the medical record (it even says so on the query). At discharge, once the coding is complete, the coders send the query back to us (we work out of case management) where we store them in the office for a year, then send to long term storage for several years (per hospital overall policy). The CDI queries are created and saved in Allscripts – which is the program we document in, but it is not considered a part of the medical record either. Our patient records are in Epic.
    ***yes, very confusing I know.

    Sharon Cole, RN, CCDS
    CDI Specialist Team Leader
    Providence Health Center
    254.751.4256
    Sharon.cole@phn-waco.org

  • paxnerospaxneros
    Actually it's not confusing at all!

    We are also Hybrid with CDI Queries being paper and NOT a permanent part of the record. Our Queries also state, "Please do not respond on this query as it is NOT a permanent part of the record."

    Once the patient is discharged we log responses into our software and the paper copy goes into a box and into storage. We haven't really decided on a retention policy at this time. As the info. is available in our software they could be destroyed. We've talked of scanning them into the business section. Right now, they rest in boxes.

    Our Coding queries ARE a permanent part of the record. If Coding has to query post-discharge the query and response is scanned into the permanent record. I can see these being subject to RAC reviews.

    But for queries which are not permanent... I would be reluctant to provide copies.

    NBrunson,RHIA,CDIP,CCS,CCDS
  • sharon.colesharon.cole
    edited May 2016
    Thank you! I 'll speak to our compliance officer and CFO and see what they say.

    Sharon Cole, RN, CCDS
    CDI Specialist Team Leader
    Providence Health Center
    254.751.4256
    Sharon.cole@phn-waco.org


  • katysuegood@gmail.comkatysuegood@gmail.com
    I noticed that the new Query brief states that they can request Queries that are not a part of the permanent record. I thought this was interesting. Seems like there is no real good reason anymore to not have the queries be a permanent part of the record.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
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