Q&A: Who can respond to a query?
Q: May a physician/provider, who does not take care of a patient during an episode of care answer a query for another physician who did take care of the patient, but does not have time to answer the queries issued to them by the CDI/coders? Could that documented response be used as a basis for compliant code assignment?
A: This subject seems to be coming up more and more lately and, the answer hasn’t changed over the years. Let’s review some information that’s essential for compliant queries and hopefully you can use it for additional education for physicians and peers related to the query process.
Per the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice (2019) page eight, “Who is Queried?” healthcare data is obtained primarily from diagnosis and procedure codes. Diagnosis codes are only assigned based on the documentation of those licensed, independent providers who render direct patient care.
The 2022 ICD-10-CM Official Guidelines for Coding and Reporting define the term providers as, “physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis.” Independent providers include physicians, consulting physicians, nurse practitioners, physician assistants, and medical residents. Code assignment may be based on other physicians’ (i.e., consultants, residents, anesthesiologist, etc.) documentation if there is no conflicting information from the attending physician. Refer to ICD-10-CM Official Guidelines for Coding and Reporting’s Section I.B.14. (p. 15-16) “Documentation by Clinicians Other than the Patient’s Provider” section for additional guidance. When conflicting documentation is present, it is the attending physician who should be queried to resolve the discrepancy.
There are occurrences for which queries are applied to individuals who are not classified as a provider. The American Hospital Association (AHA) Coding Clinic® First Quarter, 2014, states that, “It is appropriate to assign a procedure code based on documentation by a nonphysician professional when that professional provides the service.” For example, infusions may be carried out by a nurse, wound care provided by a nurse or physical therapist, mechanical ventilation may be provided by a respiratory therapist, or a medication may be ordered by the physician and administered by a nurse. In these instances, clarification may be needed from a non-physician professional and queries should be assigned as appropriate. All individuals who are likely to receive a query should be educated about the reason(s) for the query, the process, and the expectations for completion and documentation.
Another reference that maybe useful in addressing this situation can be found in State Operations Manual Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals §482.24(c) Standard: Content of Record Interpretive Guidelines §482.24(c)(1) – “All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures.”
Editor’s Note: Sharme Brodie, RN, CCDS, CCDS-O, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps, click here. This has been updated according to all new coding and documentation guidelines.