Health Information Management

Q&A: Facility policies should dictate whether queries are part of the medical record

CDI Strategies, September 2, 2010

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Q: If a CDI specialist or coder queries a physician and the response is written on the query letter is it legal to code from this? Or should the physician only respond in his or her progress note or discharge summary? Also, can the facility make the query letter part of the medical chart?

A: The answer is, as with many situations, it depends. If the form that the coder uses has been approved as permanent part of the medical record, then the physician may reply on this form and the answer can be coded. 

The term “legal” implies something governed by state or federal law. To the best of my knowledge, legal precedent has not been established addressing the use of physician query forms. Whether queries (either concurrent, retrospective, or both) are considered a permanent part of the record is a decision determined by individual facilities—generally after consulting the compliance officer and legal counsel.

Ideally, the condition documented by the physician on the “letter” or “query form” should also be documented in other parts of the record, e.g., the progress notes and discharge summary.
 
Outside agencies may “disallow” a condition if it is only documented on a query form and found nowhere else. The key to solid, audit-proof documentation is consistency and clinical support for that condition.
 
It is important that query forms approved by the facility as a permanent part of the medical record:
  • contain compliant, non-leading language,
  • include patient-specific clinical indicators
  • provide clinically appropriate choices
  • not lead the physician to only one diagnostic option
In summary, I would encourage CDI programs to establish (if you have not already done so) a written policy governing the use of physician queries in your facility. You may want to contact your state’s Quality Improvement Organization (QIO) and area recovery audit contractor (RAC) to ascertain their position on the subject of physician queries so that your policy aligns with their recommendations.
 
Editor’s note: Lynne Spryszak RN, CCDS, CPC-A, CDI Education Director for HCPro, Inc., in Marblehead, MA, answered this question on the ACDIS Blog.



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