Q&A: EHR in-basket queries

CDI Strategies - Volume 15, Issue 19

Q: Our organization received a denial stating that our EHR in-basket queries are not compliant because

  • They were answered in an email format
  • They did not adhere to published query compliance recommendations
  • They did not include the proper physician/signature authentication
  • Every entry is required to have a date and signature by the responsible party marking the entry

We are going to argue that the response does note their name and date, but is that the same as a signature?

A: First, check to see if your facility has a policy for what constitutes an acceptable query format and response. If it includes an email format as acceptable, cite that in your appeal.

Another option is to include the query in the form of a progress note or another note in the legal medical record instead. Rather than making the query a part of the business record, file it as a part of the official patient record. According to the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice, “ideally the response is filed in the medical record,” however, “organizational policies should address if the query is part of the record or stored as a separate business record.”

The practice brief goes on to say that facilities are “encouraged” to have robust guidelines in place that define the contents of the health record, making reference to a compliant query properly answered and authenticated.

Reach out to your compliance department for help on this topic and gain input from legal counsel. One would think that because an email does have a date and time stamp, it would suffice. However, the compliance and legal department should have more specific insight. They should be able to cite something formal regarding the weight of email responses, as use of email should be covered in your formal facility legal policy. You may also want to consider checking with your medical staff bylaws as to what constitutes a legal entry.

Editor’s note: This question and answer were adapted from a thread on the ACDIS Forum. To learn more about participating on the Forum, click here.

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