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News: New AHIMA physician query practice brief causes concern amongst CDI specialists

CDI Strategies, May 29, 2008

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The American Health Information Management Association (AHIMA) on May 14 issued a practice brief entitled “Queries as a tool for clinical documentation improvement,” which updates the association’s existing physician query practice guidelines from 2001. AHIMA posted the document on its Web site, available to AHIMA members only, and is allowing comments on the brief through June 2. AHIMA removed the practice brief from its Web site at the end of last week after the posting period expired.

According to Marion Kruse, RN, MBA, a director with FTI Consulting in Atlanta, the revised brief creates some serious concerns for CDI programs, including the fact that it appears to discourage physician queries about a diagnosis unless the physician has already documented the diagnosis in the record.

Page 4 of the practice brief states that, “Queries shall be initiated only when clinical indicators are present in the record and never introduce new information not already documented in the record,” which is standard practice. However, p. 9 states that, “Query forms shall not have the name of the condition, diagnosis or procedure listed on the form unless this condition, diagnosis, or procedure is already documented in the medical record and further specificity is being sought.”

“This is why we have to comment on the brief,” Kruse says. “There are things in here that will change the way clinical documentation specialists will do their job.”

The AHIMA query brief also does not allow CDI specialists to ask direct questions about a diagnosis that require a yes/no answer (except for POA queries when the diagnosis has already been documented). “Regulations are clear that the query cannot be suggested in a leading manner, suggesting the answer to the provider,” states the brief.

However, Robert Gold, MD, CEO of DCBA in Atlanta, GA, states that the brief does not provide a clear picture as to what constitutes a leading query.

“My take is that ‘leading’ has never been defined appropriately, and should mean that you don't ask for documentation when there is no clinical evidence in the health record that the condition exists,” Gold states. He offers the example of a patient who is resuscitated after a hip fracture, and his hemoglobin drops from 12.6 to 8.8 and is transfused two units of blood.

“What is leading about asking if the documented anemia was due to acute blood loss from the hip fracture?” Gold states. “It was.”

AHIMA does state that CDI specialists can use a multiple choice format in their queries, as long as they provide the opportunity for the physician to document “other” and include a line for the physician to add free text. Kruse agrees with this proposal, although she says that it appears contradictory: i.e., can one of the multiple choices be the diagnosis that the CDI specialist suspects?

The following text is excerpted from the brief and describes AHIMA’s proposed requirements for a compliant query:

The query shall be written with precise language, identifying the clinical indicators (facts) from the medical record, and asking the physician to make a clinical interpretation of these facts based on the provider’s independent professional judgment of the case. Regulations are clear that the query cannot be posed in a leading manner, suggesting the answer to the provider. Query format should not sound presumptive, directing, prodding, probing, or as though the physician is being led to make an assumption. Query forms may not be designed to ask questions about a diagnosis or procedure that can be responded to in a yes/no fashion except for present on admission queries when the diagnosis has already been documented. Query forms shall not have the name of the condition, diagnosis or procedure listed on the form unless this condition, diagnosis, or procedure is already documented in the medical record and further specificity is being sought.

Multiple choice formats can be used so long as the physician has free choice to respond. For example, list all possible choices regardless of whether or not the choice impacts reimbursement or quality reporting. The choices should also include “other” with a line for the physician to add free text as well as “unable to determine.” This format is designed to make multiple choice questions as open ended as possible.  Queries should be written in the form of a question directed to the provider to elicit a response for one condition at a time.

Kruse does state that the brief contains a lot of valuable information on how to run an effective and compliant CDI program, including the types of traits and qualifications CDI specialists should possess, expectations of those performing the query function, as well as suggestions for creating a collaborative program. “There are a lot of good things that people should take to heart as part of a good program,” she says. “If your program is only tracking dollars, you need to look at it from a much more holistic perspective.”

Note: If you would like to comment about the AHIMA query guidelines, you must submit an e-mail to Kathryn DeVault at Kathryn.devault@ahima.org by 5 p.m. on June 2, 2008.

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