Health Information Management

News: AHIMA releases long-awaited final physician query practice brief

CDI Strategies, October 2, 2008

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The American Health Information Management Association (AHIMA) on Sept. 29 released its long-awaited guidance on physician queries titled, “Managing an Effective Query Process.” The brief, which continues to focus on compliant querying, updates AHIMA’s 2001 version of a similar document titled, “Developing a Physician Query Process.”

You can read the new practice brief on the AHIMA Web site.

“Managing an Effective Query Process” is the final version of a proposed practice brief that AHIMA issued on May 14, 2008. James S. Kennedy, MD, CCS, director of FTI Healthcare in Brentwood, TN, says that the final brief significantly relaxes some of the requirements that AHIMA had initially proposed, perhaps because AHIMA received a large volume of comments submitted by providers and other concerned members of the clinical documentation community, including ACDIS.

“AHIMA pulled back after it recognized that the first part [of the proposed brief] was too cumbersome,” Kennedy said. “They made it a more manageable and succinct document. I’m very pleased with it.”

The new brief offers some concrete guidance on how CDI specialists and coders should query physicians. For example, in the brief, AHIMA states that CDI specialists can use checklists of possible diagnoses when writing physician queries, provided that the checklists contain the options of “Unable to determine,” and “Other.”

The brief also includes the following example of a correctly written query:

Dr. Jones—This patient has COPD and is on oxygen every night at home and has been on continuous oxygen since admission. Based on these indications, please indicate if you were treating one of the following diagnoses:
  • Chronic Respiratory Failure
  • Acute Respiratory Failure
  • Acute on Chronic Respiratory Failure
  • Hypoxia
  • Unable to determine
  • Other:____________________
Kennedy is concerned that some physicians may use “unable to determine” as a crutch to avoid answering a query. “Not every physician is on board with CDI,” he says.

AHIMA also acknowledged the increasing use of verbal and concurrent queries, although it does not state whether documentation specialists should record these types of queries in some permanent fashion. Kennedy says that it’s best practice to document verbal queries in some manner.  

“Any time that a query occurs, there should be some record of the query occurring,” Kennedy says, noting that some electronic databases allow CDI specialists to easily document when they perform queries, including verbal ones. “The documentation by the CDS should include that they clarified the physician’s intent in a non-leading manner.”

AHIMA adds in its brief that a query should generally include the following information:
  • Patient name
  • Admission date and/or date of service
  • Health record number
  • Account number
  • Date query initiated
  • Name and contact information of the individual initiating the query
  • Statement of the issue in the form of a question along with clinical indicators specified from the chart (e.g., history and physical states urosepsis, lab reports WBC of 14,400. Emergency department reports fever of 102)

AHIMA adds that, “It is not advisable to record queries on handwritten sticky notes, scratch paper, or other notes that can be removed and discarded. The preferred formats for capturing the query include facility-approved query form, facsimile transmission, electronic communication on secure e-mail, or secure IT messaging system.”

The query brief also makes it acceptable to ask a yes/no question regarding present on admission documentation. In it, AHIMA states the following: “In general, query forms should not be designed to ask questions about a diagnosis or procedure that can be responded to in a yes/no fashion. The exception is present on admission (POA) queries when the diagnosis has already been documented.”

Kennedy advises hospitals to consider overhauling their preprinted query forms in light of the new practice brief. “It’s a good time to dust them off and look at them and make sure there aren’t any issues with [your] policies and procedures from what is written here,” Kennedy says. Make sure your forms don’t lead physicians down the wrong path by including the name of the diagnoses in the title (e.g., ‘Sepsis query form’), he adds. Consider alternative, non-leading language, such as “Pulmonary” or “Respiratory” query form.

Kennedy also notes that the practice brief establishes HIM as the department that should “own” the physician query process. Many hospitals choose to house their CDI department within quality or case management; however, Kennedy says that hospitals should ideally situate CDI in whatever department also oversees the coding process (e.g., HIM or finance) because coders are ultimately responsible for assigning the final DRG.

Kennedy will address the AHIMA practice brief in greater detail during an upcoming HCPro audio conference on Thursday, November 6. To learn more or to sign up, go to the HCMarketplace Web site: .

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