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Q&A: Faxing physician queries (three perspectives)

CDI Strategies, February 21, 2008

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Q: Assuming that the query is worded compliantly and it is warranted by the information in the medical record, is there any CMS, AHIMA, or other authoritative body/regulation that prohibits the use of faxed physician queries? For example, may we fax a query to a physician's office? Is a faxed document a valid part of the chart if it is post-discharge and not relevant to determining a treatment plan for the patient?

A: We allow queries to be faxed and find that this practice works well. I know of no regulations that restrict this practice, but you must follow guidelines regarding the safeguard of protected health information. I did call CMS once about this issue and they didn't have a problem with it. Note that orders are faxed back and forth all the time.

(Gloryanne Bryant, RHIA, CCS, senior director corporate coding HIM compliance, Catholic Healthcare West, San Francisco, CA)

A: I don't know of any prohibitions and I think that this is strictly a facility-determined issue. At my hospital, the process went through medical staff and forms committee for approval. Also, the query is never part of the chart. Our fax query consists of the following:

1) Cover sheet with a HIPAA disclaimer
2) Our written query
3) Coding summary sheet

We use the coding summary sheet to prompt the physician to enter the "addendum diagnosis" or "addendum procedure" as well as sign and date the form; the coding summary is a permanent part of the record.

(Lynne Spryszak, RN, coordinator, clinical documentation management program, Alexian Brothers Medical Center, Elk Grove Village, IL)

A: I know of no prohibition for using a fax as a query method. However, it is less effective. Querying is a "teachable moment," and the exchange between a clinical documentation improvement (CDI) specialist and the physician is as important as the question. As for post-discharge queries, I can't imagine a fax being effective. Even a conversation with the physician about the chart is less productive retrospectively. Paper queries (fax or not) are never part of the chart in our facility, nor will they serve as "codeable" documentation.

(Pam Lovell, MBA, RN, senior director of case management and HIM, Kindred Healthcare, Hospital Division, Louisville, KY)

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