Book excerpt: Retain your queries for appeal readiness

by Trey La Charité, MD, FACP, SFHM, CCDS

The question often surfaces regarding what to do with CDI queries once they have been issued. My best advice is keep them. Most facilities do not consider concurrent queries part of the permanent medical record because physicians respond directly in the patient’s medical record. Nevertheless, governmental regulatory bodies always consider them discoverable. If the Office of Inspector General (OIG) or the Department of Justice (DOJ) asks for concurrent queries and a facility cannot produce them, you’ve got a prob­lem. More than one Assistant United States Attorney for the DOJ has publicly stated that it looks suspicious if a facility does not keep its queries. Therefore, it is considerably better to retain queries for future review than to dispose of them prematurely, possibly resulting in an unfairly biased judgment.

The second part of this debate is whether concurrent queries should be main­tained as part of the permanent medical record at all. (Post-discharge queries and their responses must already be kept as part of the permanent medical record.) The argument put forth by many facilities is this: Concurrent que­ries not intended to be, nor kept as part of the permanent medical record, do not have to be sent when Recovery Auditors request charts to review, as RAs are allowed to review only the permanent medical record.

The advantage gained here is that the RAs are denied a potential means to issue a denial since they cannot attempt to categorize a query as noncompliant or inappropriate. However, whether concurrent queries are ultimately kept as part of the permanent medi­cal record, they still must be retained for future governmental regulatory body review. Otherwise, a facility risks incurring the added liability associated with not being able to produce records when requested by the government.

Editor’s note: This article is an excerpt from the CDI Field Guide to Denial Prevention and Audit Defense.