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Pitt County Memorial Hospital

Health Information Management Services

Policy/Procedure

Manual: Health Information Management Services / Subject: Procedure for Physician Queries
Prepared by: Coding & CDI Manager / Effective Date:
Approved by: / Revised:
Reviewed:

I. PURPOSE: The purpose of this policy is to outline query processes to be used. Appropriate querying will improve the accuracy, integrity and quality of patient data; minimize variation in the query process; and improve the quality of the physician documentation within the body of the medical record to support code assignments. When the documentation necessary to assign an ICD-9-CM code for an inpatient case is not clearly stated within the medical record or is conflicting or ambiguous, a query is necessary.

1.  The ABC Hospital HIMS Department Query Policy fully applies and is incorporated with this procedure.

II. TOOLS/EQUIPMENT USED IN THE PROCEDURE:

3M Encoder/Softmed

Coding Clinic, CPT Assistant, Merck Manual, facility guidelines, ICD-9CM Coding handbook

III. PROCEDURE (Concurrent Query):

Upon the recognition for the need for a query to be posed to the medical staff, the CDS shall follow this process.

1.  Queries will be presented via the inbasket function of the Electronic Medical Record.

2.  Verbal queries are acceptable and may either be the result of a fortuitous encounter with the attending (where the written query was already submitted but not viewed) or may be a result of attempting to obtain an answer to a written query where the medical staff had not yet responded.

3.  Queries will first be directed to the provider whom is primarily documenting. Depending on the structure of the medical team, this may be a resident, a PA, an NP, or the attending. If the attending is not the provider primarily documenting, the attending should be included as a ‘cc’ recipient of the original electronic query.

4.  If there is no response within 24 to 36 hours (and at least one new progress note in the record), the primarily documenting provider will be paged for a response.

5.  If there is not a response from the initial query after 2 to 4 days and additional efforts to resolve are unsuccessful, the attending will be directly re-queried electronically and step #4 above applies.

6.  A final attempt (by page or in person) will be made to obtain a response at the time of discharge (even if the elapsed time frames above have not been exceeded).

Post Discharge Process for Unresolved Queries & CDI Worksheet Review

7.  Once the inpatient coder has completed initial coding, the record will be checked for the presence of a CDI worksheet.

a.  Upon review of the worksheet, the coder will note any queries that had been posed concurrently. Any queries that are unanswered and would potentially affect DRG assignment, have a significant potential effect on mortality profiling or that are needed to support standards of coding will be re-presented by the professional coder.

b.  In addition, the coder will also pay particular attention for any ICD-9 codes identified by the CDS but that were not coded. The coder will conduct a focused review of the documentation to identify an additional code or potential query.

c.  Queries that were answered but where the coder did not assign the ICD-9 codes will be discussed with the CDS and a determination will be made for the value of confirming the initial response to the concurrent query by re-submitting a query.

d.  The professional coder should feel free to discuss any cases with the CDS who reviewed the case (for possible queries, clinical support, difference in DRG or capture ICD-9 codes).

IV. PROCEDURE (Post Discharge Query):

The coding specialist is required to query the physician participating in the care of the patient once a diagnosis or procedure has been determined to meet the AHA Coding Clinic for ICD-9-CM official coding guidelines for reporting but has not been clearly stated within the medical record, or when conflicting or ambiguous documentation is present.

1.  The query must be submitted by the HealthSpan in-basket.

2.  General process for origination of post-coding queries:

  1. The coding professional will discuss needed queries with the reviewing CDS (identified by referencing the CDI worksheet) or if no concurrent review evident, with the CDS assigned to the discharge floor.
  2. The coding professional will specifically identify the need for the query, the anticipated or desired outcome and supporting clinical or documentation data already contained in the record.
  3. The coding professional will also refer cases to the CDS to discuss the potential need for a query or to discuss whether there is adequate clinical support in the record for documented diagnosis.
  4. If both the CDS and coding professional agree on the need for a query, the CDS will draft a query based on the input of the coding professional.
  5. The CDS will submit the query via the coding inbasket query function, signing the query with both the CDS name/phone # and the professional coder’s name. The CDS will email the coding professional and the designated coding tech notifying that a query has been submitted and include the HAR (per “Query Implementation” section below).
  6. If there is not agreement between CDS & coding professional on the need for a query, the case will be referred to the Coding & CDI Managers (or their designees).

3.  The VPMA may be consulted for advice and/or support by the Coding or CDI Manager. Areas of focus may include clinical insight, coding perspectives or assistance in resolving critical queries.

4.  Queries that are requested from other avenues of review post discharge:

  1. Avenues may include finance, RAC coordinator, quality, medical necessity, consultants, etc.
  2. CDI & Coding manager will establish process for each avenue / source of advice and review.
  3. Routine sources will be forwarded to the coding professional and CDS for execution of the query as described above in IV.2.
  4. Process for other sources will be individually determined by the Coding & CDI managers.

Query Implementation

1.  The Coding Tech will be notified by the author of a post-discharge query that a query has been presented.

2.  The Coding Tech will document it in her log.

3.  If the tech received a completed, signed query back, she will mark her log “complete”, give the information to the coder & CDS who requested the query, and be sure the completed query is now scanned into the medical record.

4.  If the query is not answered within one week, CDS will attempt to reach the physician, discuss the query and request a response.

5.  Should the physician not respond within 10 working days, the query will be scanned into the medical record and the chart will be billed without additional documentation. The Tech will document no response in the log.

6.  It is up to the discretion of the coding manager or coding supervisor if the process can be extended, i.e. if the physician has been on vacation for the last week, if he has been ill, etc.

Post Discharge Query Maintenance

1.  The physician response must be obtained within two weeks (ten work days) of the query initiation. If the physician’s response is not obtained within the 10 day time period, the query is neither considered nor acceptable for supporting the code/DRG assignment.

2.  For query responses received on cases already billed:

  1. If the physician’s response substantiates a lower weighted DRG, the claim must be rebilled following overpayment-rebilling guidelines.
  2. If the physician’s response substantiates a higher weighted DRG, the claim should be rebilled if it is within the appropriate rebilling timeframe.