From the forum: Determining query compliance

CDI Strategies - Volume 14, Issue 47

The ACDIS Forum offers a unique opportunity for members to ask questions of their CDI peers, often in real-time, for real-life input. A recent inquiry there pondered posting queries within a CDI program’s EHR physician communication system—specifically Epic’s “in-basket.” One program indicated their claim was denied because the query wasn’t officially signed due, in part, to its location.

Query responses should ideally be filed within the medical record, according to the ACDIS/AHIMA “Guidelines for Achieving a Compliant Query Practice,” Forum participants noted. However, organizations and/or CDI programs need to develop policies around whether queries are kept as a permanent part of the medical record or as a separate business document.

While the ACDIS/AHIMA practice brief does give the option to keep the query separate, it adds that incorporating queries into the patients’ charts may help avoid denials further down the line by creating a transparent chain of clinical thought processes and related documentation.

To develop a policy, Forum participants recommended asking for assistance from the compliance department with input from legal. These experts should be able to cite a formal policy regarding the weight of email responses. First, check any existing facility policies for what constitutes an acceptable query format and response, and cite that policy in defense of the claim and query. Also, check with your medical staff bylaws as to what constitutes a legal entry.

Whether you have a question about CDI expansion, management, certifications, or clinical and coding, the Forum is the best place to go for answer from those working directly in the line of CDI and facing these same struggles day in and out.

Don’t have a question, but think you might have an answer? Browse the categories and see how you can help your fellow CDI professionals as well. Current hot topics on the Forum include:

Weigh in on these discussions and others or start some of your own. Now is the perfect time to get involved with ACDIS and the CDI community virtually.

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Editor’s note: This article was adapted from a thread on the ACDIS Forum. To learn more about participating on the Forum, click here.

Found in Categories: 
ACDIS Guidance, Physician Queries