Q&A: Retrospective queries

As a benefit of membership in the ACDIS CDI Leadership Council, Associate Editorial Director Linnea Archibald sends out “missed connections” emails to Council members with questions from other members on a regular basis. Anyone with experience related to one of the questions was invited to respond and Archibald connected them with the question-asker.

In order to share the information more broadly, the answers are periodically compiled and shared as Q&A-type articles in the monthly Leadership Council newsletter, the CDI Leadership Insider (CLI). This Q&A was originally shared in the May 2022 edition of the CLI and answers have been de-identified for the purposes of this article.

Q: I’m curious what other organizations do for retrospective queries. Are the coders sending and following up on all queries after discharge or do the coders send to the CDI team (either a CDI specialist who did a review on the chart or an assigned group of CDI specialists) to create and send queries?

Council member answer #1: For our system, our CDI department owns all retrospective queries except for those we consider “non-clinical” queries. Those are queries for:

• Laterality
• Pathology
• Body mass index (BMI)

Otherwise, our CDI specialists review clinical queries and send queries to providers as necessary.

Council member answer #2: Our CDI department sends retrospective queries on any cases we review. If the coding department takes over and finds an additional query opportunity (for example, when a pathology report comes back days later), they can send their normal query or they can reach out to CDI and ask that we send it. If it’s a case we didn’t see (we do not see 100% of our patients), coding will send the query. 

We have triggers built for certain situations—for example, mortality and patient safety indicators (PSI)—that put a stop bill on the record. In that case, even if CDI didn’t review concurrently, we will review those types of scenarios and do all the querying. Whichever department sends the query, follows it through to completion. Both CDI and coding queries stop the chart from being final coded and submitted so we are able to follow up until resolution prior to final coding.     

Council member answer #3: Our CDI specialists do review discharged cases and send queries retrospectively and they are responsible for the queries. The coders are responsible for their retrospective queries if a CDI specialist has not reviewed the chart. When there is a clinical validation retrospective query, the coder will reach out to the CDI leader to request that the CDI team send it.

Council member answer #4: If a documentation opportunity is identified by one of our coders or DRG validators, the query is routed to CDI to review and issue if appropriate. If the case was followed concurrently by one of the CDI specialists, then it gets routed back to the same concurrent reviewer. If there is no CDI specialist assigned, then it goes to one of two staff members who help to cover the retrospective workflow (pre-bill reviews, and retro queries).

Council member answer #5: We have a concurrent workflow with both the CDI specialists and coders working in the same system and we use notifications to communicate details of the records. For the most part, CDI specialists perform clinical queries while coders will submit queries for conflicts, procedural issues, or cases in which CDI is not involved. The coders may also issue validation queries as needed, but it’s not as common as other query types. With a concurrent workflow, retrospective queries should be kept to a minimum so we can remain within our discharged, not final billed requirements.

Council member answer #6: At my organization, the coders send out retrospective queries, but CDI does do retrospective queries also under certain circumstances. If the CDI staff was waiting for some information prior to sending a query and the information comes back the day of discharge, they may be sending out a retrospective query. We also have a second-level review that is being done by our CDI leads. These are reviews done on a focused set of DRGs, that have been final coded, but the bills have not been dropped. They include such areas as low weighted DRG/principal diagnoses (sign and symptoms DRG, simple pneumonia, urinary tract infection [UTI], etc.), low weighted DRGs that expire or are transferred to hospice, high lengths of stay with no CC/MCC, etc. All the queries done by the CDI leads are retrospective. 

Council member answer #7: At our organization, CDI used to handle all queries, but the process changed last year to both CDI and coders doing retrospective queries. Coders query the following retrospectively:

• BMI
• UTI due to catheter
• Pathology
• Rule in/rule out
• Conflicting diagnoses
• Specificity of anemia

CDI does all the rest of the retrospective queries even if it is a case that CDI had not reviewed. Whichever team member issues the query follows through until completed. 

Council member answer #8: We have both concurrent CDI specialists and a group of CDI specialists and DRG specialists who do retrospective queries, hospital-acquired conditions (HAC), PSIs, and mortality reviews. If a coder believes a query is necessary when they are coding the chart, they will send that case and it goes into a queue that the retrospective group will review and decide if a query is needed and if so, they will place it. Coding professionals don’t place any queries themselves. Each CDI specialist will resolve their own queries once they are responded too. We have a group of coding liaisons who are responsible for following up and getting all queries answered. They place calls to offices, email, and contact the physicians with outstanding queries. Keep in mind we are a rather large health system and 100% remote, so this process works the best for us. 

Council member answer #9: The CDI team sends all queries, both concurrent and post-discharge. We “hard stop” high-risk accounts after coding and prior to claims submission. This includes:

• In-house mortality
• Accounts with a principal diagnosis of acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, and cerebral vascular accident
• HAC/PSI accounts
• Early elective delivery and obstetric complications
• Surgical complications
• DRG mismatches
• Any coder questions/queries

A CDI lead reviews these accounts and sends any queries needed and reconciles any discrepancies between what the CDI specialist and the coder assigned. If the lead and the coder cannot agree, the account is escalated for review by both the CDI manager and the coding manager. If necessary, we can pull in our medical director or vice president of medical affairs.

Council member answer #10: Our inpatient CDI team sends all the retrospective queries except the request for outstanding operating room reports. The coder is to construct the query and provide the clinical indicators as appropriate. If a CDI specialist reviewed the case, the coder sends the query request to that reviewer. If it was not a case CDI reviewed, we have an assignment rotation for coverage for retrospective queries/coder queries. CDI is not to blindly send the query, but review enough of the record to determine if it is relevant and if they agree with the indicators, construction, template selection, etc.

The CDI specialists often find opportunities to reconstruct all or part of the retrospective queries, but it is felt the coders constructing the query as best they can helps determine for them if the query truly is needed. For CDI, it keeps us as the face of the program for the provider teams and it allows us to include more supporting clinical information or inquisition into the queries.