Strategy: Follow these suggestions to help formulate compliant queries
CDI Strategies, December 27, 2007
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Opinions vary widely on what is considered "leading the physician," says Deborah Mange, RN, BSN, DRG-DOC specialist in the documentation improvement program at EMH Regional Medical Center in Elyria, OH. "I have seen queries written in all kinds of ways, and think by the very act of writing a query, you raise the issue of leading the physician," Mange says.
To formulate a compliant query that is non-leading, Mange suggests that the query should:
- Include all the clinical data that prompts the query (e.g., labs, treatments, vital signs, clinical events, etc.).
- Ask about the diagnosis, ensure that the option to disagree with the query is present, and allow the physician to propose an alternate diagnosis.
- Exclude specific monetary rewards (i.e., 'This change will add X amount of dollars to the chart.')
- Be signed by the person writing the query
Leading occurs when you ask a query without having any clinical data to suggest that a diagnosis was really present, or if you fail to provide the data that prompted the query."For example asking for sepsis when there are no labs or clinical events to suggest the patient had sepsis," Mange says.
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