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This is what others have said this past week:

“Just tell me what to pick.”

I can’t do that.

“I know I know but… just tell me this time."

When I get questions about queries from physicians, the interaction often goes something like that. Physicians understand healthcare enough to know that I can’t tell them the answer because some rule somewhere says that I can’t. That “some rule” is the Guidelines for Achieving a Compliant Query Practice and we stick to it, as most CDI and coding professionals hold themselves to a high ethical and legal standard.

What Are Queries and Why Do We Need Them?

For inpatient physicians, queries need little introduction. For the uninitiated: a query is a communication tool designed to clarify documentation in the health record, typically sent by a CDI professional or coder. Think of it as our way of ensuring the integrity and accuracy of a diagnosis, procedure, or service code (In fact, the official guidelines essentially command us to do this). In essence, queries help us:

• Clarify Ambiguous Documentation: Because, sadly, coders aren’t allowed to “read between the lines.”

• Specify Implicit Diagnoses: When a condition is clinically evident, even if it isn’t explicitly named.

• Resolve Conflicts: For example, when a consultant documents that a patient has diastolic heart failure while the attending documented systolic. Is one or the other? Or both?

• Question Unsubstantiated Claims: Like documenting hypoxic respiratory failure when the patient was neither hypoxic nor placed on supplemental oxygen.

• Confirm Diagnoses: For example, if a radiology report mentions something the treating physician hasn’t documented.

These are just a few reasons. There are many are others but you get the picture.

Compliant Queries: Dos and Don’ts

What We Must Do:

• Resolve Discrepancies: We query the attending provider unless a specialist is the better subject matter expert. Otherwise, the attending is the tie breaker and has “the final say.”

• Support with Clinical Indicators: We include relevant clinical details from the medical record to back up the query.

• Offer Alternatives: We provide an “other” option so providers can craft an alternate, accurate response. If you don’t like an answer, by all means, give an “other” answer but please write out your reasoning.

  • This is a good opportunity to remind you that these are part of the legal medical record so… don’t respond to a query with curse words directed towards your neighborhood CDI nurse.

What We Can’t Do:

• Send Multiple Queries for the Same Issue: We can’t send repeated queries until we get the answer we want. We also can’t send the same query to multiple physicians and keep the answer we like.

• Lead: We cannot bold, underline, or otherwise nudge you towards a particular answer (so I definitely can’t tell you the answer). This is one CDI professionals take quite seriously and why an answer may not be clear, because they want to give you the freedom to choose based on your experience with the patient.

• Rely Solely on Past Encounters: Queries must be based on the current encounter, although we can use previous encounters to help inform current queries

  • I’m looking at you, surgeons, who tend to document “rest of medical history in the EMR.” Except for demographic information, the coding of a patient’s medical comorbidities reset to 0 within each inpatient encounter. Failing to capture these will sabotage your risk-adjusted quality metrics.

• Query Non-Treating Providers: We cannot code from pathology and radiology reports and we cannot query non-treating providers such as pathologists and radiologists. An interventional radiologist, however, would be fair game.

• Include Reimbursement or Quality Measure Impact: Talk about leading… Yeah can’t do that either.

• Mine the Record: We cannot “mine” the prior medical record to query for the current encounter.

What We Can Do:

• Use open-ended, multiple choice, or yes/no questions.

• Send queries after discharge.

• We do not have to include “unable to determine” as an option (except if we’re asking if something was present on admission or a yes/no query).

  • By the way, as I’ve written on many times before, queries exist to help you either directly or indirectly. So, it’s not in your best interest to always answer “unable to determine” just to get the query out of your way.

Beyond the Query

While educating our hospitalists about some conditions that we were under documenting, someone asked, “Why are our capture rates so low if y'all should just be querying us for these diagnoses?”

It was a fair question.
My response?
We do consider the fact that queries contribute to burnout, so we limit queries to those that directly impact reimbursement and quality metrics.

By the way, despite answering a query appropriately, you might be encouraged to document that diagnosis in your notes anyhow. This is neither a coding guideline nor a suggestion from the compliant query practice guideline. That recommendation is a result of insurances fighting to deny diagnoses that only exist in queries.

Lastly, a physician advisor may contact you to answer a query because hospitals must stick to certain timelines to bill. Certain details are needed for charts to be billed, especially for procedures/surgeries. So if the deadline is approaching, those unanswered queries often get “escalated” to your physician advisor.

Compliant Query Practice: Beginnings

I had the opportunity to interview Brian Murphy, the original director of ACDIS, who gave us rare insight into the early days of ACDIS and how he “extended an olive branch” to AHIMA to co-write and update the compliant query practice brief in the early 2010s.

Check out that episode here. The discussion starts at about 32:45.

That’s all for now. Don’t miss out on our 7 day free trial option of our CDI and Coding Village, and don’t hesitate to ask questions as they help inspire future issues!

Cheers,

Robert

Thanks to Laura Samson, RN BSN CCDS for reviewing this newsletter! And thanks to Alicia Whiteford and Robin Dunlop for their contributions!

When you’re ready, there are 3 ways I can help you:

1. Join our CDI and Coding Village online community! It’s impossible to know it all, it takes a village! What you’ll get:

• Learn from me and other experienced professionals (perfect for new coders / CDI’s and those pivoting their career)

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