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Don't rely on paper queries: Engage physicians in dialogue

CDI Strategies, April 17, 2008

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CDI specialists who rely solely on paper queries in the medical record instead of actively engaging physicians in discussion are unfortunately not doing all they can to improve the quality and specificity of documentation, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDIS, an independent consultant located in Maryville, TN. “The impetus for a [CDI] program is to engage the physicians in behavior modification of documentation patterns,” Krauss says. “Some physicians don’t want query forms—they prefer that you talk to them.”

Placing a constant stream of notes in the record can leave a physician feeling overwhelmed, and it may eventually cause him or her to stop answering your queries altogether, Krauss adds. Remember that clinical clarification queries are far from the only notes a physician receives—other common notes found in patient records on a regular basis include requests from the patient’s family, pharmacy, nursing, case management, and physical therapy, to name a few. “Physicians are already stretched to the limit on time to begin with, and they can have as many as eight notes at one time in a record,” Krauss says. “Think about it—wouldn’t you feel overwhelmed too?”

Engaging busy physicians in dialogue isn’t always easy, but following are some tips Krauss recommends for getting their attention:

• Tie the physicians’ E/M payments to better documentation. Don’t just make it about the hospital payment and DRGs.
• Explain how proper documentation of medical decision-making and diagnoses results in better profiles and other publicly available data. 
• Offer helpful documentation and coding tips. For example, Krauss recently explained CPT critical care guidelines to a physician who hadn’t been billing critical care previously (e.g., the CPT definition of critical care, which services are included in the provision of critical care, and time requirements for reporting these services). “He was so thankful to me, now he knows what is it in for him, and he has a tendency to remember to document better,” says Krauss.

• Encourage physicians to use inpatient documentation templates that help the physician protect his or her reimbursement as well as the hospital’s reimbursement. For example, Krauss suggests developing forms to capture documentation for debridement procedures performed at the bedside and in the operating room. “Wound care debridement services have been on the OIG’s Work Plan for some time now and will continue to be, given the continued documentation deficiencies still found in medical records and despite all the publicity and attention to poor documentation patterns,” Krauss says. “[Good] documentation justifies the hospital ICD-9-CM code assignment as well as the physician’s CPT code assignment.”

In summary, Krauss encourages CDI specialists to think of themselves as business people, with physicians as their primary customers.

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