Q&A: Query compliance
Q: What are the requirements when it comes to a physician advisor asking for diagnoses to be added to the medical record? Based on the ACDIS/AHIMA “Guidelines for achieving a compliant query practice” brief, physician advisors follow the same requirement of a CDI specialist with a compliant clarification format. Do you find this is the actual requirement and/or what if the request is due to care management and the need to support medical necessity? I’ve heard that if its due to medical necessity, it’s OK for the advisor to be more direct, but I have not seen the actual language or documents to support.
A: This question is quite common. Many physician advisors feel that, because they are physicians, the rules of query compliance shouldn’t apply to them and should only be applicable to CDI specialists and coders. We know that is not true. I once had a physician advisor ask me if it was OK if he answered all the queries asked of his peers. His reasoning was that he knew what the answers should be, so didn’t it make sense if he just answered them all? After I swallowed hard, I informed him that that wasn’t compliant and that he should only be answering queries on those patients for which he was involved in the direct care.
As to your statement that you’ve heard it’s OK when it’s due to medical necessity, let’s take a look at the practice brief, p. 2 (emphasis added):
Who Should Follow This Brief?
With the evolution of reimbursement methodologies that move beyond resource use and instead focus on severity of illness, medical necessity, risk adjustment, and value-based measures, specific documentation related to diagnosis capture, acuity, and clinical validity have become even more important. The need for clear and accurate documentation and how it is translated into claims data impacts healthcare roles such as case management, quality management professionals, infection control clinicians and others. In support of organizational objectives, these professionals actively engage in educating providers to document a certain way. These individuals may not understand that their interactions meet the definition of a query, but because their practices could alter coded data, they must ensure that their practices meet compliance standards. Examples of noncompliant queries include: directing a provider to document a diagnosis that is not clinically supported but serves as an exclusion for a patient safety indicator, adding a non-reportable diagnosis, or encouraging a provider to neutralize documentation suggestive of a post-surgical complication. Although open communication between members of the healthcare team and providers is necessary and important, when it can impact claims data these discussions should be memorialized as queries. Organizations should educate all relevant professionals in compliant query practices through collaboration with health information management, coding, and CDI professionals before engaging in these interactions. Regardless of the credential, role, title, or use of technology, all healthcare professionals (whether or not they are ACDIS or AHIMA members) seeking to clarify provider documentation must follow compliant query guidelines.
This statement is pretty clear, but it may be difficult to communicate the concept to your physician advisor. My more simplified statement is: If the clarification is related directly to patient care and the treatment plan, they need not follow any directive. This is a peer-to-peer discussion working to clarify the prognosis and the plan of care. But if the discussion is related to efforts of payment/quality/medical necessity, they should follow the same constraints as one would for a CDI query. Otherwise, it could appear they were trying to lead or influence documentation in support of financial gain. This is where the rules of compliance must be enforced.
In the defense of our supportive CDI physician advisors, it is difficult to transition oneself from a clinical (direct patient care) role to more of an administrative function. Many physician advisors work in both roles throughout a single shift. I advise them to try to separate the two as much as possible. If one does not separate, the roles may blur, and the lines of compliant behavior may shift without notice.
Editor’s Note: Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC, CDI education director at HCPro, answered this question. For information regarding CDI Boot Camps, click here.