Health Information Management

Director's Note: Quarterly Conference Call raises concerns regarding compliant queries

CDI Strategies, December 1, 2011

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In the past few months, Recovery Audit Contractors (RAC) have paid closer attention to physician queries that introduce a diagnosis not previously documented in the medical record, suggested Garri L. Garrison, RN, CPC, CMC, CPUR, Director of Acute Care Services for 3M Health Information Systems Consulting Services, during the November 17 ACDIS Quarterly Conference Call.

Although not much further is known, “it is going to be interesting to see the results of these cases,” she said.
The AHIMA October 2008 guidance "Managing an Effective Query Process" and its Clinical Documentation Improvement Toolkit includes samples of compliant queries some of which do introduce a diagnosis not previously specified. The RAC attention does not appear to be “challenging the practice brief but they are questioning [queries of] a diagnosis not yet made,” Garrison said.
Best practice is for CDI specialists to bring the facts straight from the medical record to the query, use the treatments that were administered as evidence and then ask the physician to document any secondary diagnosis, she said.
“You don’t ask the physician to document hypotension or shock. You give him the clinical data and let him document what the diagnosis is,” Garrison said.
Quarterly conference call participants also discussed:
  • Outpatient CDI
  • New definition of “end of surgery”
  • Taking BMI from nursing notes
  • Expanding clinical knowledge as a CDI specialist
Editor’s Note: The recording of the November 17 ACDIS Quarterly Conference Call is available online for members.

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