PAGE: 1 of 8 / REPLACES POLICY DATED: April 1, 2001; June 1, 2002
APPROVED: November 12, 2002 / RETIRED:
EFFECTIVE DATE: December 15, 2002 / REFERENCE NUMBER: HIM.COD.012
SCOPE: All personnel responsible for performing, supervising or monitoring coding of inpatient services including, but not limited to:
Facility Health Information Management Administration
Corporate Health Information Management Services External Coding Contractors
Case Management/Quality Resource Management Ethics and Compliance Officer
Service Centers Physician Advisors
This policy applies to queries initiated for all inpatient services provided in Company-affiliated facilities (acute care, freestanding psychiatric, and rehabilitation) unless otherwise indicated in a separate policy. For queries specific to the assignment of ICD-9-CM code of 482.83 (Pneumonia due to other gram-negative bacteria), refer to Company Policy Memorandum entitled Special Coding Practices on ICD-9-CM Code 482.83 dated October 20, 2000. For outpatient services, refer to the Coding Documentation for Outpatient Services Policy, HIM.COD.002. For skilled nursing services, refer to the Coding Documentation for Skilled Nursing Facilities/Units Policy, HIM.COD.010. For Coding Documentation for Rehabilitation Facilities, refer to HIM.COD.013.
PURPOSE: The purpose of this policy is to define when a query will be initiated and outline the appropriate 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. A query is an established mechanism of communication between coders and physicians to clarify ambiguous, incomplete or conflicting documentation in the medical record in order to facilitate complete, accurate and consistent coding practices. The Company has developed six (6) approved standardized query forms. The selection of the appropriate standardized form will be determined based on the type of query being initiated. Two of the standardized query forms are to be used for pneumonia; three of the query forms are to be used for sepsis; and one query form will provide a template to be used for all other queries. The approved and required standardized query forms are attached to this policy (see Attachments A-F).
POLICY: 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 required (unless otherwise indicated in a separate Company Policy Memorandum). Company facilities will follow the Official Guidelines for Coding and Reporting diagnoses and procedures published in AHA Coding Clinic for ICD-9-CM, Fourth Quarter, 1999 and Second Quarter, 2002 and/or the most current AHA Coding Clinic for ICD-9-CM Guidelines.
PROCEDURE:
1. The Query Process
The coder 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. Implementation guidelines provide additional guidance on appropriate queries and are located on the Company’s Intranet site on the Health Information Management Services page.
a. Query Documentation
The query documentation must include:
(1) the name of the individual submitting the query;
(2) the patient’s name;
(3) the patient’s medical record number;
(4) the patient’s account number;
(5) the date the query was submitted;
(6) an itemization of clinical findings pertinent to the condition/procedure in question including the source document(s) from the medical record supporting the query; and
(7) the statement of the issue in the form of a question.
b. Query Format
i) If a query is necessary to clarify ambiguous or conflicting documentation in the medical record in order to facilitate complete, accurate and consistent coding practices, the query must be documented on one of the approved separate query forms.
NOTE: Do not pose more than one question on the query form. It is appropriate to ask the physician multiple questions, however, each question must be on a separate query form.
ii) The approved query forms include all of the required query elements and are attached to this policy. (See Attachments A-G).
iii) The selection of the approved query form will be determined based upon the specific type of query that is being initiated. The determination of the appropriate method or approach to the query must be based on the following:
(1) Pneumonia:
i. If the physician has documented pneumonia in the medical record and there is a positive sputum culture, use query form A to determine if further specificity related to the type of pneumonia can be obtained.
ii. If the physician has documented pneumonia in the medical record and there is not a positive sputum culture, do not query. However, if there are extensive clinical indications of aspiration pneumonia, see iii immediately below.
iii. If there are extensive clinical indications of aspiration pneumonia, use query form B as a means to clarify if aspiration pneumonia is or is not present. By extensive, it is meant that the physician has substantially described aspiration pneumonia but has not made the specific or particular diagnosis.
iv. If the purpose of the query is not included as one of the above conditions, use query form F.
(2) Sepsis
i. If the physician has recorded the diagnosis of sepsis and there is no positive blood culture, a query is not necessary and sepsis should be reported based on physician documentation.
ii. If the physician has documented sepsis in the medical record and there is a positive blood culture, use query form C to determine if further specificity related to the type of sepsis can be obtained.
iii. If the physician has documented a localized infection (e.g., urinary tract infection, cellulitis) and there are extensive clinical indicators of a generalized sepsis, use query form D. By extensive, it is meant that the physician has substantially described the clinical condition of sepsis, but has not made the specific or particular diagnosis.
iv. If the physician has documented a localized infection (e.g., urinary tract infection, cellulitis) and there are not extensive clinical indicators of a generalized sepsis, a query is not warranted and the code assignment should report the highest level of specificity based upon the physician documentation in the medical record.
v. If the physician has documented urosepsis and there are extensive clinical indicators of a generalized sepsis and clarification is needed to determine whether this is a localized urinary tract infection or a generalized sepsis, use query form E.
vi. If the purpose of the query is not included as one of the above conditions, use query form F.
(3) Acute Blood Loss Anemia
i. If the physician has recorded the diagnosis of unspecified anemia and there is no documentation of an acute blood loss, a query is not necessary and anemia should be reported based on physician documentation.
ii. If the physician has documented anemia in the medical record and there is documentation of an acute blood loss, use query form G to determine if further specificity related to the type of anemia can be obtained.
iii. If the physician has documented extensive clinical indicators of acute blood loss anemia, use query form G. By extensive, it is meant that the physician has substantially described the clinical condition of anemia, but has not made the specific or particular diagnosis.
iv. If the physician has documented blood loss and there are not extensive clinical indicators of an acute blood loss anemia, a query is not warranted and the code assignment should report the highest level of specificity based upon the physician documentation in the medical record.
v. If the purpose of the query is not included as one of the above conditions, use query form F.
(4) Any Other Queries
For any other query that is required to clarify ambiguous, incomplete or conflicting information contained in the medical record, use query form F.
c. Maintenance of the Query Form
i) The coding query process can be conducted and documented on a concurrent (pre-discharge), retrospective (post-discharge) or post initial billing basis.
ii) The query may be posed verbally or in writing; the query (whether verbal or in writing) must be documented on one of the approved and required standardized query forms; and maintained in the body of the medical record.
iii) The facility must ensure that the reimbursement received by the facility is appropriate based upon the acceptable medical record documentation.
iv) If the purpose of the query process is not for clarifying ambiguous or conflicting documentation for coding purposes, e.g., certification for insurance purposes, follow the applicable facility policies regarding the maintenance of the this information.
a. Concurrent - A concurrent query is defined as one that is initiated before the patient has been discharged from the facility. The concurrent query is initiated to clarify documentation for the purpose of final code assignment.
b. Retrospective – A retrospective query is defined as one that is initiated after the patient has been discharged from the facility, but before the claim has been billed.
c. Post Initial Billing - The post initial billing query is defined as a query that is executed as a result of additional documentation (e.g., discharge summary) being added to the record or findings during a retrospective coding review (internal or external) that occurs after the claim has been billed.
i. Query initiation for post initial billing can only occur within 12-months of the discharge date.
ii. The physician response to the query must be obtained within 2 weeks (14 calendar days) of the query initiation and must also be within 12 months of the discharge date. If the physician’s response to the post initial billing query generated is not obtained within 2 weeks, the query is neither considered nor acceptable for supporting the code/DRG assignment.
iii. If a chart needing the query is beyond 12 months from the discharge date, a query should not be initiated.
iv. If the physician’s response substantiates a lower weighted DRG, the claim must be rebilled following Company overpayment rebilling guidelines.
v. If the physician’s response substantiates a higher weighted DRG, the claim should be rebilled if it is within the appropriate rebilling timeframe (60 days from the remittance advice date).
d. Query Response
The query response from the physician that will be used to support a code assignment must be documented by the physician in the body of the traditional medical record and/or, at a minimum, on the query form (which must be kept as a permanent part of the medical record). The traditional medical record is defined as the customary forms, based on the patient type, which are contained in the medical record to furnish documentary evidence of the course of the patient’s illness and treatment during each hospital admission. If the patient has been discharged, the response to a (retrospective) query must be documented in the body of the medical record by the physician and be signed and dated with the date that the information is added to the medical record. The response must be in the form of a late entry progress note, an addendum to a dictated report (e.g., discharge summary, H&P, consultation), or as an inclusion in the dictated discharge summary or, at a minimum, the response must be on one of the six approved and required coding query forms. If the local Peer Review Organization (PRO) is requiring the query response to be documented in the body of the traditional medical record, the response must be in the form of a late entry progress note, an addendum to a dictated report (e.g., discharge summary, H&P, consultation), or as an inclusion in the dictated discharge summary.
e. Billing and Delinquent Record Count for a Chart with a Query
i) Any chart awaiting a response to a query must not be final abstracted (final billed) until the physician’s response is documented on the query form and/or in the body of the traditional medical record or the physician has responded that no addition to or clarification of the medical record is necessary.
ii) Any query requiring a physician response must be included in the incomplete and delinquent record count until the response is received and documented in the appropriate place in the medical record or the physician has responded that no addition to or clarification of the medical record is necessary. This requirement must be reflected in the medical staff bylaws or rules and regulations.
f. Medical Staff Approval Process
If medical staff approval is necessary, the Health Information Management (HIM) Director must submit the standardized query forms for approval following the process outlined in hospital policy or medical staff bylaws or rules and regulations for adding forms to the medical record.
g. Query Education and Tracking
i) All facilities should educate their physicians on the importance of concurrent documentation within the body of the medical record to support complete, accurate and consistent coding.
ii) Communication should be provided to the medical staff that coders or representatives of HIM and/or Quality Resource Management will query physicians when there are questions regarding documentation for code assignment.
iii) Communication must clarify that the query will be documented in writing and that the physician response must be included on the query form and/or within the body of the traditional medical record.
iv) Queries must be tracked in order to facilitate improved documentation and appropriate release of the claim for billing purposes.
v) Administration and medical staff leadership must support this process to ensure its success.
2. Query Guidelines
In order to achieve consistency in the coding of diagnoses and procedures, coders must:
a. Follow procedures that result in complete, accurate and consistent coding and accurately represent the patient’s diagnoses and procedures for the relevant episode of care;
b. Adhere to all official coding guidelines as stated in this policy;
c. Assess physician documentation to ensure that it supports the diagnosis and procedure codes selected;
d. Consult physician for clarification and additional documentation prior to final code assignment when there is conflicting or ambiguous data in the medical record;
e. Not use the word “possible” in a query unless specified in the physician documentation;
f. Assist and educate physicians and other clinicians by advocating proper documentation practices, further specificity, resequencing or inclusion of diagnoses or procedures when needed to more accurately reflect the patient’s episode of care;
g. Follow the procedures as outlined in this policy to document an appropriate query; and
h. Query the physician if the physician has substantially described a clinical condition but has not made a diagnosis. The query must be documented on the appropriate approved and required query form attached to this policy.
3. Facility Query Compliance Monitoring
Internal facility-directed (which includes coding supervisors) or certified external vendor (which excludes Corporate HIMS, Independent Review Organization and Internal Audit & Consulting Services) coding quality reviews must be completed semi-annually (or more frequently as directed by facility leadership) by each facility.
a. Reviews must include review of the query process to determine query appropriateness and accurate code assignment with comparison to the UB-92 claim electronic vendor bill, and/or remittance advice to determine accurate billing.
b. Findings from these reviews must be utilized to improve the query process, coding and medical record documentation practices and for coder and physician education, as appropriate.
4. Company-Wide Query Compliance Monitoring
Compliance with this policy will be monitored by the Corporate Health Information Management Services Department.
a. It is the responsibility of each facility’s administration to ensure that this policy is applied by all individuals involved in the coding and querying of medical record documentation in inpatient records.
b. Employees who have questions about a decision based on this policy or wish to discuss an activity observed related to application of this policy should discuss these situations with their immediate supervisor to resolve the situation.
c. All day-to-day operational issues should be handled locally; however, if confidential advice is needed or an employee wishes to report an activity that conflicts with this policy and is not comfortable speaking with the supervisor, employees may call the toll-free Ethics Line at 1-800-455-1996.
For any questions regarding this policy, please contact the HIMS P&P Helpline at 1-800-690-0919 or by the e-mail address: HIMS P&P Helpline.
REFERENCES:
Coding Documentation for Outpatient Services Policy, HIM.COD.002
Coding Documentation for Skilled Nursing Facilities/Units Policy, HIM.COD.010
Coding Documentation for Rehabilitation Facilities Policy, HIM.COD.013
Special Coding Practices on ICD-9-CM Code 482.83 Policy
Coding Clinic for ICD-9-CM is the official publication of ICD-9-CM coding guidelines and advice as designated by four cooperating parties: American Hospital Association (AHA), American Health Information Management Association (AHIMA), Centers for Medicare and Medicaid Services (CMS), and the National Center for Health Statistics (NCHS).
Practice Brief on Data Quality, American Health Information Management Association (AHIMA), Chicago, Illinois, February 1996.
AHIMA Standards of Ethical Coding, American Health Information Management Association (AHIMA), Chicago, Illinois, Revised December 1999.
Health Information Management Compliance, A Model Program for Healthcare Organizations, Sue Prophet, Chicago, Illinois, 2000 Edition.
CMS memorandum to the Peer Review Organization entitled “Use of the Physician Query Forms” dated January 22, 2001.
CMS memorandum to the Peer Review Organizations entitled “Use of Physician Query Form” with Policy Clarification of Temporary Suspension of January 22, 2001, dated March 21, 2001.
12/2002