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Update physician query policy in light of new AHIMA practice brief

Association of Clinical Documentation Improvement Specialists, January 5, 2009

With ICD-10 closer than ever, it’s crucial that your hospital has an effective physician query process. The new coding system, which CMS proposed in August 2008, is more specific and may result in more physician queries.

The looming switch to ICD-10 is part of the reason the American Health Information Management Association (AHIMA) published its “Managing an Effective Query Process” practice brief, says Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, president of Safian Communications Services, Inc., in Winter Park, FL, and a member of AHIMA’s National Classification Practice Counsel. Now is the perfect time to reexamine documentation patterns and query practices in light of more specified and detailed codes, Safian says.

Audit your current process

In all likelihood, your hospital already has some sort of physician query process in place. “Overall, [the new practice brief] is probably a refresher,” Safian says.

Also, AHIMA is not a regulatory body; it’s a professional association making recommendations and providing guidance for individuals who work in the healthcare industry, says Gloryanne Bryant, BS, RHIA, RHIT, CCS, senior corporate director of coding and HIM compliance at Catholic Healthcare West in San Francisco.

“The practice brief is just that. It’s a practice brief,” Bryant says. “The brief isn’t CMS law.” This concept is something that coders and other individuals performing queries sometimes misunderstand, she says. She encourages all HIM professionals to read through the brief and use it as a tool when drafting query policies.

Hospitals should at least be able to use it as a starting point to update old procedures initiated years ago, when the hospital still used paper charts, Safian says.

The best way to determine the effectiveness of your current query process is to conduct an audit. First and most importantly, ensure that your querying method is legal and ethical. Next, look at specific aspects of the process:

  • How are queries delivered to the physicians? Are queries electronic or paper-based?
  • How must physicians respond? In what time frame?
  • Are there certain physicians who consistently don’t respond in a timely manner or don’t respond at all?
  • Are there physicians who receive queries more frequently than others?
  • Are the queries necessary, and do they include appropriate language? Do they introduce any new information to the medical record?
  • How well does the process work?

Once you understand the gaps or problem areas in your query policy, you can start incorporating suggestions from the AHIMA brief.

Go back to the basics

Your hospital’s query policy must include all of the elements you audited and more. AHIMA makes several recommendations. At its most basic, your policy should explicitly specify the following:

Who to query. Should it always be the attending physician? Are there circumstances that require querying the consulting physician or the surgeon?

When to query (in which circumstances). According to the brief, “Queries are not necessary for every discrepancy or unaddressed issue in physician documentation.” Clarify which clinical conditions and what types of documentation warrant one.

“There needs to be a clinical significance to query the physician,” Bryant says. “One of the things we don’t want to do is overburden [physicians] with queries.”

When to query (during the process). Make sure you know whether to reach out to the physician while the patient is still in the hospital, after the patient has been discharged, or after a claim has been submitted. Not all situations will fit into one mold, so the policy should allow the individual performing the query function to make a judgment call, when appropriate.

The policy must also include a time frame for the physician response. “Does your policy say, ‘Doctors need to answer the query as soon as possible’? which is incredibly vague,” Safian says. “That never works for anyone.”

Bryant says for concurrent queries, she expects to receive a response within 24–48 hours. For retrospective queries or those initiated at the time of coding (i.e., after discharge), that time frame may extend to three or four days. Base your time-frame expectations on your state’s requirements for medical record completeness after patient discharge. For example, California requires record completion within 14 days.

How to query. Specify exactly what information a query should cover and in what format. Most queries include the patient’s name, admission date, medical record number, account number, date of query, name and contact information of the person initiating the query, and a specific question about the physician’s documentation.

Note that this specific question can never lead a physician to document a certain diagnosis.

“We’re not here to tell the clinician what to write,” Safian says. “We’re just here saying we need more information to code this correctly.” A leading query—particularly one that results in a higher-reimbursed diagnosis—could be construed as fraud, she adds.

Remember to address yes/no and multiple-choice questions in the policy. “We don’t promote a policy of check boxes for diagnosis or procedure,” Bryant says. “We prefer that there be physician initials next to the diagnosis choice or a written narrative.”

What to do about physicians who don’t follow your facility’s policy. Writing down a specific action plan can help immensely when, for example, a physician simply ignores a query. Will you note the physician’s delinquency in his or her personnel record? Does it become part of the chart of the patient in question?

Safian suggests keeping track of which physicians are queried most often, as well as those who don’t respond quickly enough. Provide targeted education for these physicians.

Tackle two tricky situations

Targeting education to noncompliant physicians sounds easy on paper. And in the scheme of coding queries, it is manageable compared to two slightly trickier scenarios: verbal queries and situations in which the coder disagrees with a physician’s clinical diagnosis.

Verbal queries have the greatest liability from a legal standpoint and because they are a common source of miscommunication, Safian says. Your policy must clearly state that verbal answers to verbal queries do not constitute documentation. The physician’s response must appear in writing (or electronically) in the record.

“You can actually watch a doctor put stitches in a patient and count them,” Safian says, “but you can’t code it until the doctor writes it down.” As the saying often goes, if it wasn’t documented, it didn’t happen.

Bryant supports verbal interactions. In fact, she says they’re an effective way to further educate physicians about why querying is crucial and how ICD-9 classifies diseases and procedures. For that reason, she keeps an ICD-9 manual handy so she can open the book and show visual examples to physicians and other clinicians.

After that, it’s up to the physician to turn the conversation into written documentation. As the AHIMA brief states, “The desired result of a verbal query is documentation by the provider that supports the coding of a condition, diagnosis, or procedure.”

Aside from verbal queries, another gray area is when the documentation and clinical indications don’t align with the written diagnosis. When a serious discrepancy occurs, the query may not be the appropriate solution, Safian says. “There are peer reviews and other channels through the hospital that are the proper avenues to take up a case like that,” she says.

Your policy should state outright when to query versus pursue other avenues, as well as which other avenues to use. For example, CDI specialists or other individuals initiating the query function should speak up when they think a lab result or symptom is missing from the documentation. However, Safian says it’s not the job of the person performing the query to question a physician’s judgment. “We need to do everything possible to not make this an adversarial position,” she says.

As with any other type of major process change, it’s crucial to educate all parties involved.

“The truth is, and I say this all the time, I can’t do anything about how much Congress is going to assign to an RVU for payment,” Safian says. “What we can do as health information management professionals is to make sure that every dollar available that you’ve earned, you get. The only way to do that is with complete documentation.”

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