Health Information Management

Q&A: Coder vs. clinical documentation specialist queries: ACDIS advisory panel members weigh in

CDI Strategies, September 18, 2008

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Q: Are there different standards for coders and RNs regarding queries? Also, I do not see verbal queries in the American Health Information Management Association (AHIMA) proposed physician query practice brief. If this proposed brief were to pass as-is, would a CDI specialist be able to query physicians verbally on the floor?
 
A: Lynne Spryszak, RN; Colleen Garry, RN, BS; Gloryanne Bryant, RHIA, CCS; Tamara Hicks, RN, BSN, CCS: Even when we verbally query the physician, we write it up so that we have a paper record of what we did for data capture purposes. I would expect all RNs to back up a query with supportive clinical information.
 
Currently, the only industry guidelines are those that AHIMA publishes. AHIMA is in the process of revising its practice brief, and the new brief is expected to be published in the October Journal of AHIMA. There is a lot of discussion about the role and ability of clinicians to query and to what extent they can “lead” a physician to a diagnosis.
 
Verbal querying can be done and is often preferred. When performing a verbal query, consider asking the physician to provide a written clarification in the progress notes. Then make a note in the query tracking log to indicate that it was a verbal query and that you obtained a written reply. Also, track verbal queries and ensure that clinical indicators are preent before specialists initiate a query. 

A: Robert Gold, MD: There are no standards written for anyone but coders. What we have to consider is the ethics of doing what we do. If a CDI specialist or coder asks for documentation regarding conditions that are not supported anywhere in the medical record, they are playing with fire. For example, if they ask for documentation of gram-negative pneumonia when a patient is being treated with the usual regimen for what the medical staff calls CAP (community acquired pneumonia), or if they ask for documentation of uncontrolled diabetes when all the physician documents is perioperative use of insulin to stabilize a Type 2 patient's sugars, that's bogus.



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