Q&A: Defining ‘direct care’ in query practice

Q: We would like to clarify the definition of "direct care" as it pertains to the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice—2022 Update brief. Recently, several providers and leaders have asked about querying "alternative" providers. Here are some scenarios we've encountered along with our responses:

• Request: Query the physician assistant (PA) instead of the surgeon when the PA wrote orders but did not document a note.
  Response: If the PA was involved in the patient's care and is familiar with their situation, they can address the query.
• Request: Ask the pathologist to addend pathology results.
  Response: Although the pathologist is a physician, this would be noncompliant since they did not provide direct care to the patient.
• Request: Query the PA who assisted in surgery.
  Response: This is acceptable because they were involved in the patient's care, though it’s not ideal as they didn’t see the patient outside of the operating room or write orders.

With that being said, we have one scenario that raises some uncertainty: Is it appropriate for the night coverage hospitalist, who is responsible for the patient, to address queries?

They receive hand-off reports from the day team and may be called to see the patient or write orders overnight. They also manage lab results that arrive during the night. We believe this provider could adequately read the query and review the chart to respond. Our compliance team, however, feels it wouldn’t be appropriate if they haven't physically seen the patient or documented a note.

A: It sounds like you have a clear understanding of what is required. The passage from the query practice brief means that when you have questions or need information about a patient's care, those questions should be directed to the healthcare providers who are actively involved in the patient's treatment during that particular encounter.

For instance, if a consultant or physician is currently caring for the patient, they should be the ones to respond to queries. It would be inappropriate to ask someone who isn't directly involved in the patient's care, like a physician advisor who isn’t treating the patient, to answer questions.

Additionally, the organization (like a hospital or clinic) needs to have a plan in place for what to do if the primary treating provider is unavailable—like being off duty or no longer on the case—so that queries can still be appropriately addressed. Your medical bylaws should indicate who is responsible for medical record documentation. Most facilities state the attending provider is ultimately responsible for the documentation accuracy and completeness of the medical record.

For diagnosis reporting, only physicians and designated providers (PA or NP) that have physically assessed the patient and correlated the diagnostic information and findings should report diagnoses regarding the encounter. This is a requirement of their professional fee billing. In the case of the night hospitalist, they can answer queries if they have familiarized themselves with the medical record, findings, and have also performed an appropriate physical assessment of the patient to develop an informed decision related to the diagnosis or question being asked.

To answer your question: the provider who answers the query must have sufficient knowledge to respond appropriately. For example, could you query a provider for the acuity of congestive heart failure if they did not physically have eyes on the patient and do an assessment? No, they cannot respond appropriately.

Again, if the documenting provider is submitting for professional fee billing, they must have met the medical decision-making and/or time component for billing purposes which does include diagnosis, data, and risk assessment. Best practice is to direct queries to those that have day to day interaction with the patient and can make appropriate and well-informed decisions on their care. Anything else may be setting the organization up for compliance concerns.

Editor’s note: Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS, director of CDI education at ACDIS/HCPro, answered this question. Contact her at deanne.wilk@hcpro.com.