Health Information Management

Q&A: Creating compliant verbal query processes

CDI Strategies, March 3, 2016

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Q: Can you clarify the expectations related to documenting the discussion between a physician and a CDI specialist when a query is done verbally. The 2013 ACDIS/AHIMA physician query practice brief Guidelines for Achieving a Compliant Query Practice expanded on the need to document this interaction and we’re wondering if our process is compliant.

We write out the query form and discuss it with the physician. If the physician agrees, he or she adds the detail into the medical record. On the completed form, we simply add a “V” or the words “verbal query.”

Do you have any additional advice? How do you recommend programs track verbal queries for compliance?

A: Not all verbal interactions between the physician and the CDI specialist rise to the level of a verbal query, says ACDIS Advisory Board member Anny P. Yuen, RHIA, CCS, CCDS, CDIP, director of ambulatory CDI at Enjoin. 

All CDI programs need to establish policies and procedures surrounding verbal queries and how they are tracked. All organizations should have a permanent record of verbal query language in order to demonstrate compliance and allow for adequate quality monitoring.

Such policies should follow guidance from ACDIS/AHIMA, agrees ACDIS Advisory Board member Judy Schade, RN, MSN, CCM, CCDS, CDI specialist at the Mayo Clinic Hospital in Arizona, who offers the following tips:

  1. Determine if the verbal discussion was educational or related to a documentation opportunity.
    1. If the CDI specialist presents the physician with specific clinical indicators, diagnostic results, interventions, and treatment plan related to a particular patient with an expected outcome then it is a verbal query.
    2. If the discussion relates to general documentation tips regarding a diagnosis or disease process, it’s likely educational in nature.
  2. Verbal queries need to follow the same compliance standards as written queries, so the CDI specialist needs to document that query and ensure there was no mention of a diagnosis, and the intent of the query (e.g., if the query was to clarify conflicting documentation in the record). CDI staff also needs to include the applicable:
    1. clinical indicators
    2.  treatments
    3. diagnostic results
    4. progress notes
    5. nursing notes
    6. possible diagnosis options along with “other” or “unable to determine”
  3. Monitor and trend verbal queries for educational and quality purposes just as with written queries. “These can be used in outcome assessments so it’s very important that verbal queries are documented and reviewed,” Schade says. 

The important focus is that all queries should follow the same policy/procedure/process and are not leading or offering the diagnosis, she says.

Click here to read the rest of the Q&A on the ACDIS blog.

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