Health Information Management

Topic: Establish a policy that addresses how and when to use query forms

HIM-HIPAA Insider, May 15, 2007

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Last week, HIM Connection brought you ways to improve your documentation by using effective queries or by initiating a comprehensive re-education of clinicians. Read on to learn how your HIM department should establish a policy that addresses how and when it will use query forms.

Your HIM department should obtain physician input when developing a policy. Have your hospital's HIM and compliance department committees review and approve the policy. In some cases, Coding Clinic advises coders to ask for additional information from the physician. However, your organization's policy should not permit the use of general queries (for example, all cases where there is no noted secondary condition but should permit queries that are patient-specific.

The policy should include a copy of the query form, but should prohibit the use of "sticky notes," for obvious reasons.

The query form should

  • Be clear and concise
  • Contain precise language
  • Present the facts from the medical record and identify why clarification is needed
  • Present the scenario and ask the physician to make a clinical interpretation of a given diagnosis or condition based on treatment, evaluation, monitoring, and services provided
  • Provide open-ended questions that allow the physician to document the specific diagnosis rather than multiple-choice questions requiring only a "yes" or "no" response
  • Not be designed so that all that is required is a physician signature
The form should include

  • The patient name
  • The admission date
  • The medical record number
  • The name and contact information (e.g., phone number and e-mail address) of the coding professional
  • A specific question and rational for question (i.e., relevant documentation or clinical findings)
  • A place for physician to document his or her response
  • A place for the physician to sign and date his or her response

Once coding managers have established the query policy and procedure, they need to create a mechanism for tracking the query process. This mechanism could be a deficiency in the deficiency-tracking system or simply an old-fashioned tickler file.

It takes effort to issue queries and obtain answers to them in a timely fashion. Coding managers must diligently follow up on unanswered queries or expect to see a rise in the discharged not final billed. At some point the manager must "fish or cut bait." That is, coding managers must determine how long they will wait for an answer before coding the record with what they have and dropping the bill. Establish this time fram in the policy.

Coding managers should also periodically review the queries to ensure that the content and style of questioning is neither challenging nor leading. This review may identify patterns of documentation deficiencies for a given condition or diagnosis, or for one or more physicians. With this information, you can initiate a focused or widespread educational program.

Editor's note: The above article was adapted from the book Coder Productivity: Tapping your Team's Talents to Improve Quality and Reduce Accounts Receivable. For more information or to order, call 877/727-1728 or click here.

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