Q&A: Develop policies regarding query retention

Q: We are implementing a new electronic CDI system. Our concurrent queries are not currently a part of the medical record. The providers document their responses in the progress notes. We believe this adds to the consistency of the medical record and will avoid any issues related to auditing from external agencies. Recently, however, our physicians have requested to document their responses directly on our concurrent queries, which will then make the queries a part of the medical record. Are you aware of any best practice issues or ideas regarding this area?

 

A: The AHIMA practice briefs offer no standard practice guidelines about query retention. However, the 2001 AHIMA “Developing a Physician Query Practice” states:

 

“Any decision to file this form in the medical record should involve the advice of the facility’s corporate compliance officer and legal counsel, due to potential compliance and legal risks related to incorporating the actual query form into the permanent record (such as its potential use as evidence of poor documentation in an audit, investigation, or malpractice suit, risks related to naming non-clinicians in medical record, or quality of care concerns if the physician response on a query form is not clearly supported by the rest of the medical record documentation.”

 

Each organization must review the issues and develop policies to ensure consistent practice amongst all departments. Concurrent and retrospective queries should follow the same process for retention. Many organizations have chosen to allow physicians to respond on the query form and maintain this form within the record.

 

If you choose to make your query forms part of the medical record, make sure the forms are properly labeled with patient information (identifiers) and dated and timed as these forms will be considered part of the progress notes. No matter how the query forms are retained (within the medical record or as part of the business record of the account) your query process, templates, etc., must be written in a compliant manner.

 

As an organization you must develop and follow your own policies with the guidance with direction from the query practice briefs and Official Guidelines for Coding and Reporting. The 2013 joint query practice brief from ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice suggests that organizations review their query practices and policies on a regular basis to ensure compliance. It sounds as though with your upcoming software changes, now is a perfect time to review your practices and policies. Review every query template to ensure compliance, as well.

 

Auditing agencies and CMS are fully aware facility staff—whether they are coders or CDI specialists—query physicians. Many reviewers, therefore, are asking to see the query forms. The 2007 Federal Register instructs hospitals to make attempts to improve all aspects of clinical documentation. It states:

 

 

There should be no fear of transparency with your query practices if you are following ethical and compliance standards consistently.

 

If you choose to make the change to place your query forms as part of the medical record make sure that your medical staff is completely aware of this change, and that they have taken part in the decision. Discuss this with leaders within your medical staff, your organization’s compliance team, and quality teams, as well as those who supervise the coding practices within your organization. Make these discussions a part of a thorough review of all policies related to physician documentation queries. I also suggest that those who are reviewing the policies be well versed with the various industry query practice briefs for reference.

 

You are not alone in trying to determine the best practice for this issue.

 

Editor’s Note: Laurie L. Prescott, MSN, RN, CCDS, CDIP, is a CDI Education Specialist with HCPro Inc., in Danvers, Mass., and a lead instructor for its CDI-related Boot Camps. For more information regarding upcoming Boot Camp dates and locations visit www.hcprobootcamps.com/courses/10040/location-dates.