Health Information Management

Q&A: ACDIS Advisory Board weighs in on physician query form retention

CDI Strategies, July 9, 2009

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Q: Our facility is wondering how long to keep queries. In a previous institution in which I worked, the queries were not a part of the medical record and we only kept them and our worksheets for about three months to a year maximum. 

The rationale there was that once documentation was secured and the billing completed, we no longer needed the worksheets or queries. However, in my current hospital we keep all worksheets and queries.  These take up a lot of space.  The furthest we may refer to these would be about two to three months post-billing.  We do have our Excel spreadsheets that include our queries in brief, such as, "CHF specificity," with the response and where located. 

We would like to know the ACDIS Advisory Board's recommendation on how long to keep the actual queries as our queries are not a part of the medical record.  Would the board consider the queries discoverable during an audit?

A: Garri Garrison: I see mixed opinions across the United States. From my experience, approximately 80% of hospitals do not have the query as part of the permanent medical record. Of those, most only keep them about six months, and probably 20% keep them a year. I’d estimate only 20% keep queries as a permanent part of the medical record. In my opinion, it is a hospital-specific decision. The direction the facility takes should be whatever their external/internal legal counsel is comfortable with.

Shelia Bullock: Our compliance department approved our policy to not include queries as a permanent part of the medical record. Our current policy requires six-month retention of the queries and then the queries are shredded. Involve your compliance department on this decision.

Robin Holmes: I concur with the comments regarding compliance ... seek your compliance officer’s opinion. At our facility we keep the queries as part of the permanent medical record. If you do not have the query as a permanent part of the medical record, you may be at risk when it comes to a Recovery Audit Contractor (RAC) review. We have been informed that certain RAC consulting groups have implied that the hospital deliberately did not query for documentation that would change the MS-DRG to a lower paying MS-DRG.
For example, consider a patient admitted with c/p and a diagnostic heart catheter. After workup, it appears the problem is gastrointestinal. Because a heart catheter MS-DRG is desirable, no one queried to clarify the etiology. Or, maybe someone queried but it is not on the medical record. Without that query in hand, you have no proof of the attempted clarification.
When you query with the focus of accurate documentation to reflect the history of the hospitalization, you will be focused on compliance and not money. If you are writing compliant queries, you should never have an issue with anyone viewing them.
Gloryanne Bryant: The Catholic Healthcare West’s position on this, which included compliance and legal departments in the discussion, was to keep our queries as a permanent part of the record. I recall the compliance officer saying: "We have nothing to hide.” So the queries are kept as long as the medical record is kept. Go to your compliance and/or legal staff for guidance.
Jean Clark: At our facility CDI queries are not part of the medical record, however coding queries are. We took this to our medical record committee for approval.
Pam Lovell: In my opinion, the most important consideration is to have a hospital/department policy that describes the entire query process and to make sure each CDI specialist adheres to it. Personally, I believe the record speaks for itself and that queries should be shredded. However, it is important to keep queries long enough to collect data for trend analysis to spot process improvement and educational needs to measure physician participation.
Robert Gold: This is some great commentary from everyone. As long as it's not a retrospective "query," my outlook is that if the record speaks for itself, you don't need record of a concurrent clarification. If there is documentation that is complete in progress notes, consults and discharge summary, and if the documentation fully supports the clinical picture (because the concurrent interactions with the physicians either took place early enough in the patient's stay, or there was no need for further clarification because the documentation was perfect from the get-go), then the medical record speaks for itself.
I encourage early documentation intervention and solid physician education regarding the importance of documentation. Certainly, if it could look to someone evaluating the record from an audit perspective that the record has been tampered with or influenced by an outside force, I would think that maintaining a record of some sort would be protective and wise—concurrent or retrospective.

The more we roll out our CDI programs to all payers, to all medical specialties, well beyond only issues that affect MS-DRG assignment and into true and honest representation of the code sets for all conditions, the more we are protected against insinuations of upcoding.

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