Health Information Management

Q&A: Queries under RAC scrutiny

CDI Strategies, November 12, 2009

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Q: We recently heard from our process management company that after several clients have had the Recovery Audit Contractor audits that we can no longer use a diagnosis in a query that has not been brought up in the progress notes. Is this true? This makes writing a query much more challenging!

A: The AHIMA physician query practice brief published in October 2008 listed the following nonexclusive circumstances for which physician queries are appropriate:

  • Clinical indicators of a diagnosis but no documentation of the condition
  • Clinical evidence for a higher degree of specificity or severity
  • A cause-and-effect relationship between two conditions or organism
  • An underlying cause when admitted with symptoms
  • Only the treatment (not the diagnosis) is documented
  • Present on admission (POA) indicator status
Moreover, the brief states that multiple choice questions are an acceptable practice and they even show an example that lists specific diagnoses. When using a multiple choice format they note that there must be a number of options that are clinically reasonable, along with “other” and “clinically unable to determine.”
I learned a lot from my time in New York and California during the demonstration project. One especially important thing I learned is that the RAC does not always do a good job of researching their positions. Many of their findings have been overturned at higher appeal levels.
Editor’s Note: Marion G. Kruse, MBA, RN, Director at FTI Consulting, and co-author of The Physician Queries Handbook answered this question.

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