Q&A: Creating a query process with coding

Q: I am working with my coding manager to solidify a coding/CDI query request process that works for all, but so far have had some roadblocks. What is the process or policy for query requests from the coding department to the CDI department at your organization? Are there specific query types (DRG shift impact, complications, etc.) that coding always sends to CDI? Are there specific query types that coding never sends to CDI? Is there a conflict resolution in place for when CDI does not agree with the request?

Response #1: Our CDI team sends all the queries. When the coder has a query request, it is sent as a notification, then someone from the CDI team sends the query and follows our escalation process if needed. If the CDI specialist does not feel a query is needed, but the coder does, it is escalated to both the coding and CDI managers, and a decision is made between those two parties. It works well. The queries are always consistent when they are going to the provider since the same group is always sending it. The providers are very familiar with our team, and we have an established escalation process.

Response #2: Our CDI team reviews cases concurrently, but we do have a process for coder requests. This includes DRG mismatches that are not subsequent documentation, patient safety indicator (PSI) 90s that are flagged, present on admission (POA) mismatches on risk variables, certain diagnoses that have not been validated by a CDI specialist, anything that a CDI specialist was following for, and any query opposition or question requested by coding. When CDI specialists cannot yet validate a certain diagnosis during a concurrent review, they are instructed to write “FOLLOWING” in all caps at the end of their review. As we all know, sometimes these cases get discharged before we get back to them. The “FOLLOWING” note helps prompt the coder to send the case back to get it validated or clarified by the CDI specialist prior to billing.

The coding department can send anything back if they have a question or a query request. It does not always mean that we will query, but it opens that conversation and allows one last look at the record. We try to focus on impactful queries. For example, if hypokalemia was documented but not supported with the labs, we would not necessarily send a query for clinical validity. But we would send a query for any CCs/MCCs that are not supported, of course. We have a list of diagnoses that we always validate on any record (acute kidney injury [AKI], sepsis, malnutrition, etc.) and would query if not supported.

We communicate via EPIC work queues (WQ). Coding sends the question or request to a leadership WQ, and the supervisors filter through these daily and route coder requests to another WQ for our CDI team to work up. The individual CDI specialist gets their own cases back. Any of those that don’t include a CDI review used to be assigned randomly to our CDI staff, but now we have a group of CDI professionals that strictly work up coder requests.

We have an escalation process in place as well. If the CDI and coding specialists do not agree more than once (such as coding requesting a query but CDI refusing, and then coding still requesting the query), we ask that it gets escalated to the CDI supervisors or coding supervisors. If the supervisors cannot agree it will get escalated to the managers, but this is rare. The escalation is also done through the EPIC WQs.

Here is an example of what coding sends back to CDI, which also applies to no CDI review cases. If there was a one-day length of stay sepsis case that was not assigned to a CDI, it would be sent back to the CDI team to review to validate the sepsis diagnosis.

What Records Need to Be Sent for CDI Team Lead – Review Needed at Time of Coding

(This includes all patient types, no exclusions)

• DRG mismatches UNLESS they are subsequent documentation 
• PSI 90s  
• When CDI says “FOLLOWING” (Please send to CDI Team lead WQ #) 
• Any of these diagnoses that are not validated clinically OR no CDI review/not seen by CDI concurrently 

• Acute respiratory failure 

• Acute kidney injury

• Sepsis or septic shock 

• Severe malnutrition 

• Encephalopathy 

• Pressure ulcers 

• Simple pneumonia
• Risk variables that have POA mismatch between coding and CDI OR if CDI did not see the chart and coding assigns a POA of N, then send back to CDI

CATEGORIES (see PowerPoint with detailed list of codes) 

1. Cachexia 

1. Cardiac arrhythmia 

1. Chronic fatigue 

1. Coagulation defect 

1. Fluid/electrolyte disorders 

1. Liver failure 

1. Metastatic cancer 

1. Pulmonary heart disease 

1. Severe brain conditions 

1. Thrombocytopenia 

• ALL query opportunities identified by coding 

Response #4: At our organization, we have worked closely with coding for more than eight years. We have a buddy system that pairs our CDI specialists with coders (not subcontractors) in their region, as we have 17 facilities reviewed by CDI specialists. Coding and CDI specialists send notifications to their buddy and can request a review of a diagnosis for criteria, correct coding, or any other needs. Our job aid states that coding is to request CDI send all clinical validation queries on questionable documented diagnoses. If a CDI specialist is not on the case, the coder will request their CDI buddy review the case and add the query, if needed.

CDI leaders over the past seven to eight years have written and updated over 80 of our own queries. These are approved by compliance and coding leadership, then uploaded into EPIC and our vendor software. Coding uses these EPIC queries on accounts post-discharge if needed. Because the CDI department has physician advisors and a response rate of about 1.7 days for over 2,500 queries per month, the coding specialist can also request through notifications that the CDI specialist assigned on the case send these post discharge queries. A few of our more seasoned coders will send queries but must send compliant queries. This process builds good relationships with coding and has been successful.

Response #5: Coders will reach out to the CDI specialists if they are not sure why their DRGs do not match. If the reason for the mismatch is due to subsequent documentation or a coding rule, the coder will mark the case to reflect that and will not reach out to the CDI specialist. 

CDI specialists will reach out to coders if they see the coder has not captured the result of their query in the coder’s codes. (Our system flags the CDI specialist to let them know this.) CDI specialists and coders communicate via email for the reconciliation process. If there is a disagreement on either side, both the coding and CDI managers are tagged into the email.

We have new functionality that gives us greater detail about the mismatch between CDI and coding, and we are starting to work with our coding counterparts to develop workflows on how we leverage the new functionality, so our processes may change after we learn more. 

Response #6: In my opinion, the deciding factor that will drive the process is whether the mismatch process is conducted pre-bill or post-bill. If the discussion takes place pre-bill, the CDI team may not have insight into the coders’ pending DRG.

The most common practice I have seen is “one and done,” in which the coder reaches out pre-bill to the primary CDI specialist, and the CDI specialist will respond. If they do not reach agreement with this “one and done,” the case is escalated to respective CDI and/or coding leadership. Another practice I’ve seen, if the CDI team is doing post-bill reconciliations, is that the CDI reviewer will reach out to coding leadership (i.e., a supervisor or quality specialist) and will request a re-bill. Then a determination will be made whether to re-bill or not.

Response #7: At our organization, the adult coders send queries when they identify an opportunity while coding the record, with the exception of clinical validation queries. Those are only written by a CDI specialist, and we have a second level review team who handle validation requests post-discharge. We also have a process in place where a coder can send a record to a second-level reviewer if it is a complicated query request or they would like more clinical input regarding the need for a query.

For our pediatric facility, the CDI specialist writes all queries. We also use concurrent coding for our pediatric facility, and the CDI specialist and coder collaborate throughout these long length of stay cases. If a coder identifies a possible query need, they reach out to the CDI specialist who then determines if a query is needed or not.

Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council. For the purposes of this article, all Council member answers have been deidentified.