Symposium Spotlight: Creating compliant query practices in outpatient CDI

Editor’s note: Rita Fields, BSN, RN, CCDS, recently retired from her role as regional CDI manager at Baptist Health in Louisville, Kentucky, and was named CDI Professional of the Year in 2017. Susanne Warford, MBA-HCM, RN, CCDS, is the system CDI analyst and appeals nurse for Baptist Health in Louisville, Kentucky. She serves as the President for the Regional KY/Southern Indiana ACDIS Chapter. The two will present “Is Your Outpatient Query Process Compliant?” on Day 1 of the ACDIS Symposium: Outpatient CDI. This year’s Symposium takes place November 8-9, at the Hilton Orlando Lake Buena Vista—Disney Springs area. To see the complete agenda, click here. To register, click here.

ACDIS: What’s the most challenging thing about writing a successful outpatient query, in your opinion?  

Fields: Making sure you have all the relevant information necessary to write a compliant query. Time management can be a problem in a busy CDI program, so information can be missed. Even experienced CDI professionals can get too focused on productivity and forget to slow down, look for all the clinical indicators describing the situation, and bring those forward to make the query easier for the physician to understand and respond appropriately.

Warford: I agree, definitely ensuring that the CDI specialist has gathered all of the relevant information from the medical record and incorporated that into the clarification, so the query can “stand alone,” can be a challenge but it’s one that outpatient professionals need to face.

ACDIS: What do you think about the evolution of the query practice over the past 10-plus years?

Fields: I like the fact that AHIMA and ACDIS joined forces to create the 2013 (revised 2016) Guidelines for Achieving a Compliant Query Practice to provide clear guidance to anyone that writes a query. I also appreciate the recent ACDIS position paper “Queries in outpatient CDI: Developing a compliant, effective process,” and I understand that ACDIS and AHIMA are currently in the process of drafting a new practice brief that could address both inpatient and outpatient query practices. I am looking forward to making sure that our efforts align with those recommendations.

Warford: The emphasis on clinical validation in the CDI world (both inpatient and outpatient), has helped to ensure compliance which is leading to better data collection and outcomes.

ACDIS: Have electronic systems helped make the query process easier? How so? 

Fields: The electronic systems have definitely improved the query process. It helps CDI with time management through query templates, adds queries to the EHR where they are easy to find and easier for physicians to respond. CDI professionals no longer have to track down charts and place the paper queries by hand. 

Warford: Electronic queries have definitely improved the query process, I agree. Queries are less intrusive (physicians aren’t hiding from CDI staff and staff aren’t interrupting their day), allowing the physicians to respond on their own time. Additionally, queries are easier to store, track and monitor for compliance.

ACDIS: Do you prefer prospective, concurrent, or retrospective record reviews and queries? (Or do you think all three types are necessary in the outpatient world?) 

Fields: I wish I could say that one works better than the others, but depending on your review process, you may use all three. Prospective queries would be my choice to use. It allows the physician to address any documentation concerns during patient encounter. Physicians seem to dislike the retrospective queries because they take longer to research to provide an appropriate response.   

Warford: Prospective queries are probably the best in the physician practice because they allow the physician to address during the concurrent visit. Oftentimes in the physician practice, it is difficult to do a concurrent query due to the length of time of the visit. Retrospective queries are much more labor intensive on the physician. All three query types are necessary, though.

ACDIS: What are some of the query challenges on the outpatient side? 

Fields: I think CDI professionals face many of the same challenges on the outpatient side as you do on the inpatient side, including physician education on why queries are written, documentation needed, and rationale behind the query. Also, physicians understanding coding guidelines and risk adjustment can be an obstacle to overcome. Physicians just aren’t taught the rules behind code assignment and even though many in the clinic setting assign their own codes, they do so as a matter of rote response to drop-down menus, electronic prompts, and past knowledge. Helping them understand why code assignment matters and the reasons behind the coding rules, goes a long way to ensuring not only support for outpatient CDI efforts but also in their own compliant documentation and billing habits.

Warford: I think, since it a relatively new arena for CDI, there is still a struggle getting “buy-in” from the physicians in the clinics. Due to the various geographic locations, education can be quite difficult. You have to employ many different techniques when trying to educate the physicians. Some, you may never see face-to-face, so those queries really need to serve double duty and act as an educational tool for them as well.

ACDIS: What piece of advice would you give to CDI professionals transitioning to the outpatient world from an inpatient background?

Fields: You have an advantage because you already know the inpatient guidelines and CDI processes, but you need to know all the outpatient guidelines and how they are different or the same. You also need to be able to communicate with a physician with confidence and provide correct information. Once the certified clinical documentation specialist outpatient version is available and you are qualified to sit for it, I recommend sitting for the test as soon as possible.

Warford: Due to the fast pace of outpatient CDI efforts, you will need to streamline the way you review charts to ensure you are capturing all of the relevant information needed for accurate code assignment.

ACDIS: Do you prefer Sesame Street or the Muppets? Who is your favorite character? 

Fields: Sesame Street (Big Bird)

Warford: Muppets (Statler and Waldorf)