Health Information Management

Q&A: Do not alter queries after issuing

CDI Strategies, April 10, 2014

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Q: Is it is okay to alter, add to, or take back a query form after the physician answers it?

A: There are two basic situations that support the need for a query.  The first and most common situation is when there is evidence of an incomplete, vague, or missing diagnosis based on clinical indicators in the medical record. The other situation is when a diagnosis is documented that is not supported by clinical evidence. 

This latter situation requires a nuanced approach, however. It isn't up to a CDI specialist or coder to define a condition with particular clinical indicators, nor is Coding Clinic a definitive source for clinical indicators. My litmus test for whether or not a diagnosis is supported by clinical evidence is whether other providers would reach the same conclusion based on the same clinical evidence.

For example, although many providers use American Society for Parenteral and Enteral Nutrition (ASPEN) criteria to support the diagnosis of malnutrition, it is not incorrect for a provider to make that diagnosis based on albumin levels. These were an accepted clinical indicator for years, so other providers would likely come to the same conclusion based on the same evidence. 

Remember CDI and coders are not diagnosticians, and our role is not to judge the quality of care, but to ensure that a diagnosis meets the definition of a reportable diagnosis before assigning a code (e.g., meets the definition of a principal or secondary diagnosis, is documented by a provider who is delivering direct patient care, is related to this episode of care, is not integral to another condition, etc.).

I cannot think of a situation where it would be acceptable to alter a query or remove a query once the provider addresses it. I would go one step further and suggest that even if the provider does not answer the query, it would be inappropriate to alter or remove it. Although organizations are not required to keep the query as part of the legal health record, they are at a minimum supposed to keep it as part of the business record.

A query is discoverable and should be made available to auditors as requested.  Verbal queries should be memoralized in the same format as written queries for the purpose of transparency.

My recommendation is to refer to the various AHIMA physician query practice briefs, which discuss standards of when to issue and how to construct a query. The latest industry standards, developed in partnership with ACDIS, (Guidelines for Achieving a Compliant Query Practice) builds on the briefs and collective knowledge of government payment, compliance, and auditing practices. 

This 2013 document stresses that the reason for the query is as much, if not more, significant than the construction of the query. Queries are vulnerable to scrutiny for several reasons.  Below are a few examples.

  • Were there sufficient clinical indicators to justify the query?
  • Is the documentation open to interpretation?
  • Do coding guidelines require specific documentation like a cause-and-effect relationship?
  • Is it clear which condition is the principal diagnosis or is it an unusual occasion where more than one diagnosis could be the principal diagnosis?

Additionally, the 2013 document recommends that if the provider documents on the query form itself, then it should be retained as part of the permanent health record. If the query is part of the health record then it must comply with all authentication requirements associated with the medical record.  I know of no situation where a record can be altered following provider validation except by the provider when it is clearly identified as an addendum or alternation. 

Your CDI program/organization in consultation with the medical staff should determine whether to keep queries as a permanent part of the legal health record or not. I do recommend that if HIM/coding queries are retained as  part of the health record than concurrent CDI queries should also be part of the health record, as it would be difficult from a compliance standpoint to justify why one is part of the health record and the other is not.

However, even if the query form is not governed by authentication requirements associated with the legal health record because it is only part of the business record, it would be inappropriate to alter a document validated by another physician. It also appears to be an ethical issue as the integrity of the CDI and the provider could be affected by altering a document that was already addressed. The impact of a query is usually recorded as a CDI performance metric. Most CDI departments monitor queries for:

  • Response rate
  • Agreement rate
  • Effect on the claim

Therefore, altering a query could alter CDI metrics.  It could also mask CDI performance issues, such as not understanding when a query is warranted as well as issues with query construction.

The best course of action would probably be to "close" the query and then reissue a new query with the new and/or updated information; however, this may be frustrating to the provider if they already responded once to a similar query.  A query that requires additional revision after submitting it to the provider may be a learning opportunity for the CDI constructing the query so they are able to be more precise and accurate the next time they construct a similar query.

Editor’s Note: CDI Education Director Cheryl Ericson, MS, RN, CCDS, CDIP, to Associate Director, Education for ACDIS, AHIMA Approved ICD-10-CM/PCS Trainer, answered this question. Contact her at cericson@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview.This article was originally published on the ACDIS Blog.



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