RAC, queries, and the new Practice Brief

sharon.colesharon.cole
edited May 2016 in CDI Talk Archive
In the new Practice Brief, under the section: Develop Query Retention Policies, the very last sentence states: Auditors may request copies of any queries in order to validate query wording, even if they are not considered part of the legal health record.
Our queries are not considered a part of the legal medical record, but are retained in the office for 1 year and then sent to long term storage for 6 years. If a physician answers on the query ONLY, the diagnosis is not coded by our coders.

Based on the above sentence in the new practice brief, if the auditor requests queries, do we send them? If we do not, can we be penalized for not sending them?

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

Comments

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    To me, it sounds like they CAN request them, but it does not say that you must send them with a general med records request. I'm not sure on this though. Ours are part of the medical 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
  • canipeccanipec
    edited May 2016
    Our process is the same as yours Sharon, although, RAC has requested our query document and it was reviewed by them. Even though the query is not a part of the permanent record per our policy, our queries can be accessed through our software.

    Carol Canipe RN, BSN, CCDS
    Clinical Performance Improvement
    704-834-4980
    Caromont Health
    Gastonia, NC 28053
  • cselukecseluke
    edited May 2016
    That sentence was not meant to give auditors permission to ask for
    queries; they already do that. It was included simply to acknowledge
    that some hospitals choose to not make queries part of the permanent
    record. Each hospital is advised to make a policy about record handling
    and retention of queries that are NOT part of the permanent record.
    Hospitals that classify queries as a business document would handle them
    according to internal policy.

    Cathy L. Seluke, RN, BSN, ACM, CCDS
    Supervisor Clinical Documentation Compliance
    MaineGeneral Medical Center
    Augusta and Waterville, Maine
    P. 207.872.1796
    F. 207.872.1594
    Cathy.Seluke@mainegeneral.org
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