Health Information Management

Q&A: Revising query policies for alignment with new practice brief

CDI Strategies, June 20, 2013

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Q: I am in a new CDI program and revising our physician query policy. While the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice (released February 2013) states that it: "...augments and where applicable supersedes prior AHIMA guidance on queries," I was wondering if those organizations who updated their policies just added escalation and query retention policies and kept the main body of their original policies unchanged?  

I am also wondering if we should amend our policies to include the more specific information addressing the various query formats (multiple choice, verbal, etc.) or if simply stating staff should follow the ACDIS/AHIMA Guidelines would be enough?
A: “Since the most recent ACDIS/AHIMA query practice brief had some additional detail in regards to multiple choice format and other topics, I do intend to update our policies to reflect that additional guidance particularly in regards to ‘yes/no’ queries and to diagnosis not clinically supported,” saysACDIS Advisory Board member Donald Butler, RN, BSN, CDI Manager, Vidant Medical Center, in Greenville, N.C. “I already had a policy in regards to query retention, so don't think that will change. I also definitely need to develop escalation process, however, as a collaborative process that will take a bit of time to work out.”
One reason to include additional detail from the latest query practice brief is for emphasis. Furthermore, incorporating such details helps to ensure that everyone has a common understanding of the expectations, Butler says.
Not all policies need to be revised for the new practice brief, however. “I reviewed our existing policies and found that the changes would not impact our guidelines or were already addressed in our guidelines, so we do not have any plans for revisions,” says Robert S. Hodges, BSN, MSN, RN, CCDS, CDI specialist at Aleda E. Lutz VAMC, in Saginaw, Mich. 
Regarding question how queries are retained, Hodges advocates for specificity and consistency within written policies.
“For example, our policy indicates the verbal queries must follow the same format as written queries and that the content of the query must be retained in our electronic query tracking system. As such we document a summary of the conversation we had with the provider for verbal queries or copy and paste a copy of the electronic query into the system and add their responses when received.”
Whatever you end up doing will depend on how your process runs and the resources you have available to you, says Hodges, but consistency on how queries are sent, managed, and retained should be considered.
Editor’s Note: This Q&A was adapted from a thread on the CDI Talk discussion board.

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