From the Forum: Tips to ensure verbal query compliance

Composing and documenting verbal query interactions often confuses CDI specialists. While the guidance published by ACDIS and AHIMA holds for all queries, written and unwritten alike, gauging a verbal query’s compliance can be a tricky business. Some even prefer the verbal format because they feel it allows them to lead the provider to the desired answer—it doesn’t, as Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CDI Education Director at HCPro in Middleton, Massachusetts, pointed out a couple weeks ago.

Recently, the topic of documenting/memorializing a verbal query came up on the ACDIS Forum yet again. One ACDIS member wondered if physicians need to sign the documentation of that verbal query interaction.

Part of the answer depends on how the physician’s answer to the query is carried over to the medical record. If queries are a part of the legal medical record and could be the only place a diagnosis is documented, for instance, the physician’s signature may be warranted on the queries. On the other hand, if they’re not part of the medical record, the physician may not need to sign the query, but they do need to carry the subsequent documentation of the diagnosis over to the record.

“Our verbal queries are maintained in our CDI software (not part of the medical record) and adhere to AHIMA[/ACDIS] standards for compliance,” said Jackie Touch, RN, MSN, CCM, a CDI specialist at CHOC Children’s in Orange, California. “The CDS makes sure the diagnosis is documented in the medical record by the MD if they agreed, then indicates in the software the appropriate disposition.”

Others in the discussion also stressed the importance of documenting the verbal query in general. “Our verbal queries are documented by the CDI RN and they are not signed by the MD,” said Janie Brown, RN, the director of clinical documentation accuracy at Community Health Network in Indianapolis, Indiana. “However, verbal queries are held to the same standard as written queries when it comes to compliance. It is important to show that you are not leading the physician.”

No matter what way the query answer is memorialized in the record, compliance across all query forms should be king. “Please understand, I love verbal queries and interaction with providers,” Prescott says. “But when we verbally query, the same rules apply as if those queries were in writing.”

Editor’s note: This article was adapted from a discussion on the ACDIS Forum. For information about joining in on the conversation on the Forum, click here. To read Prescott’s article on query compliance, click here.