Q&A: Clinical documentation specialist vs. coder queries: Two ACDIS members provide their thoughts

A: Our CDI specialists (both inpatient coders and RNs) seek documentation clarification concurrently, and although we strongly promote verbal clarification and having a conversation with the MD, we use written clarification forms. Our concurrent query process and form is a little different than our retrospective physician query at the time of coding/discharge forms. We are now moving to having a “documentation clarification form” for concurrent use and a “physician documentation query” for coding use.

The concurrent query would have some additional clinical information and there is space for that on the form to list clinical indicators and signs/symptoms to support the clarification. We are not keeping the concurrent clarification form as a part of the permanent record because the physician documents the diagnosis on the progress notes.

We keep the coding physician query form as a permanent part of the medical record at all times. This serves us when performing a quality check on the coding staff to see what queries they are using and if they are querying. We also promote the physician to write the information in the progress notes or as an addendum to the medical record (if it is obtained post-discharge) on the coding query form, but otherwise the form is used as the addendum and it’s left in the chart retrospectively, but not concurrently (this was a recent change in our process). All clinical documentation and forms are always signed and dated.

We do not have a problem with the QIO either and have had a close working relationship in the past with them on the coding query process back in the days of the PEPPER reports.

(Gloryanne Bryant, RHIA, CCS, senior director of corporate coding and HIM compliance for CHW in San Francisco, CA, answered this question).

A: Our CDI (all RNs) queries are different from the coding queries as they are more clinical in nature. The expectation is that the physician will document in the medical record the information prompted by the RN query. The queries are not part of the medical record. However, coding queries after discharge are part of the medical record and must be signed and dated by the physician. We have not had any problems with QIO reviews of medical records.

(Jean Clark, RHIA, service line director, HIM, CDI and accreditation for Roper St. Francis Healthcare in Charleston, SC, answered this question).

Questions?

Do you have a CDI-related question? Submit it to ACDIS Director Brian Murphy at bmurphy@hcpro.com.