Health Information Management

Tip: Pay attention to query retention

CDI Strategies, September 16, 2010

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Retaining written, templated, and verbal queries in document form is necessary to ensure CDI compliance. In the current climate of regulatory agencies (e.g., recovery audit contractors and Medicare administrative contractors), it’s a good practice to maintain queries as part of the permanent medical record to demonstrate compliant and ethical coding practices, said Gloryanne Bryant,  BS, RHIA, RHIT, CCS, CCDS, during the July 14 audio conference, “AHIMA CDI Practice Brief: What it Says and What it Means for Your Program.”

“The query should be retained indefinitely if it contains information not documented in the health record. Auditors may request copies of any queries in order to validate the query wording, even if they are not considered part of the legal medical record,” says Bryant.
 
Maintaining queries as part of the health record can be helpful for cases in which physicians assert that they were unaware of an existing query for further documentation. Keeping queries as permanent documents in the health record can also help to reduce potential query redundancy and decrease the risk of retrospective queries, she said.



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