Q&A: Queries as part of the permanent record
Q: We’re attempting to make provider queries part of our medical record which coding can use to pick up codes. Does anyone have experience with this they could share? We are interested in: Components of a query (complaint query), who to send the query to, who is responsible for launching a query, if providers are required to respond, any reasons responses may be excluded from being recorded (for inappropriate provider responses), etc.
Response #1: All our queries are part of the business record, but they aren’t incorporated into the actual progress notes.
One of the metrics we track is query response rate. These are incorporated into physician scorecards the goal is that the providers respond in under two days, though this is not explicitly stated in the policy. If the provider responds with a “non-response,” meaning the response is not aligned with the query, then we would follow up with the provider to get clarification. If the response is not aligned with organizational definitions of a certain diagnosis, we would escalate the query to follow up before we closed the query.
Response #2: We follow the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice brief, which is a great place to start.
For compliant queries, we use the TRIC method (Treatment, Risk, Indicators, Compliant question) which was created by Sheila Duhon, MBA, RN, CCDS, CCS, A-CCRN. She wrote a book about it titled CDI Workbook: Investigating Complex Cases and Formulating Queries. CDI specialists must have the TRIC components on every query which will effectively construct compliant and impactful queries. For us, all queries are a permanent part of the record, once answered by the provider. So, all responses count, and we do trend those responses for improvement every month. Here are some responses and meanings below:
- Query sent: A query has been sent to a provider
- Agreed: The physician responded with a clinically supported response
- Alternate codable response: The physician provided an alternate condition that can be coded
- Disagreed: The physician responded and did not agree with the intent of the query
- Un-codable response: The physician responded with a response that could not be coded
- Unable to determine: The physician was unable to determine a response to the query
- No response: The physician did not respond to the query
Response #3: we follow the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice brief for components of a query.
For whom to send the query to, it depends on the query topic. Typically, it’s the attending; however, for queries related to a surgical procedure, we will query the surgeon and physician’s assistant/nurse practitioner if the attending is a hospitalist. Also, for surgical patients, if the query is for a diagnosis not related to surgery, we will query the hospitalist if the attending is the surgeon.
All our concurrent queries are sent by CDI specialists and our retrospective queries are sent by our coders. Providers have until 24 hours after discharge to respond to concurrent queries. If there is no response, the query is automatically marked “no response” and a retrospective query is followed-up by the coder.
Provider query responses are automatically part of the medical record and filed as a provider note in EPIC, unless the provider chooses the option for “refer to clinical documentation reviewer.” This option gives the provider a way to ask the query sender a question without the question becoming part of the medical record.
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.