/ HIM = Query Documentation Policy / SOP #
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Standard Operating Procedure – Query Documentation

1.Purpose

The purpose of this policy is to establish a process to clarify documentation regarding diagnosis, conditions and/or procedures that are representative of the patient’s severity of illness, risk of mortality, and resource consumption during an inpatient hospitalization. It also defines when a query will be initiated and outlines the appropriate query processes to be utilized.

A compliant query process will ensure the accuracy and integrity of the patient chart. Queries will assist in a more accurate picture of the patient’s clinical condition and severity of illness. It will promote more accurate ICD-10 coding and Present on Admission (POA) assignment.

Queries will be initiated when documentation is illegible, incomplete, unclear or contradictory.

2.Scope

This policy applies to all coding staff initiating inpatient queries and to physician’s answering the query.

3.Procedure

  1. Query Process

A query may be generated by a Coder. A query may be initiated when the medical record documentation:

  1. is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent with clinical documentation found in the record
  2. includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure;
  3. provides a diagnosis without underlying clinical validation or etiology
  4. is unclear for POA indicator assignment
  1. Query Documentation

The approved query forms include all of the required query data elements for an appropriate query.

  1. Query Format
  2. The query process can be conducted and documented on a concurrent (pre-discharge), retrospective (post-discharge) or post billing basis.
  3. The query may be posed verbally, in writing, or electronically utilizing one of the approved and required standardized query forms; and must be maintained as part of the medical record.
  4. Verbal queries must be documented in writing. The physician must provide the response to the query and authentication within the body of the medical record or on the query form.
  5. The query must include clinical indicators, give the provider reasonable options, and must include the ability to respond that no additional documentation or clarification can be provided.
  6. The query can be taken to the physician, faxed or the physician can be asked to come to the medical record department.
  7. The yes/no query format may only be utilized on query forms that have the printed yes/no query responses. These query forms are to be used in the following circumstances:

a.Substantiating or further specifying a diagnosis already present in the health record;

b.Establishing a cause and effect relationship between documented conditions; and

c.Resolving conflicting documentation from multiple practitioners.

  1. It is appropriate to ask the physician multiple questions if there are multiple conditions,diagnoses, proceduresand/or POA indicators that require clarification, however, each question must be on a separate query form unless they are related.
  2. Queries should not be repeated in an attempt to receive a particular outcome.
  1. Query Response

a.The response to a query (including the physician’s documentation of the sign, symptom, condition, diagnosis, procedure or POA indicator) must be documented by the physician and be signed, timed and dated with the date/time that the information is added to the medical record.

b.It is not acceptable for a clinician to document a verbal response from the physician as a result of a query anywhere within the medical record.

c.When the physician’s response dictates a rebill, the rebill process must be initiated promptly.

d.When no additional documentation can/will be provided by the physician in response to a concurrent query, the query should be updated by the physician and/or person performing the documentation review that no additional documentation is warranted or will be provided.

  1. Delinquent Record Query
  2. Any chart awaiting a query response should be held no longer than the delinquency timeframe.
  3. A decision to hold the chart for longer than this period must be approved by the director or administration.
  4. A chart being held for a query will count as a delinquency and guidelines for notification of the physician, of a delinquent record, should be followed.
  5. If the query remains unanswered, documentation should be on the query form that no response was received and the account can be final billed.
  6. No account should be held longer than the timely filing guidelines.
  1. Tracking Queries
  2. Queries will be tracked to facilitate and support documentation improvement efforts.
  3. Queries will be tracked for timeliness of response.
  4. Queries will be monitored by provider and education will be provided as needed for providers and coding staff.
  5. The query process will be monitored to improve coding, documentation and the query process itself.

6.References

Managing an Effective Query Process, American Health Information Management Association (AHIMA), 2001

The Physician Query Process and Compliance Issues, HCCA, 2010

Guidelines to ICD-10 Coding: Centers for Disease Control

7. Definitions

Query: A query is an established mechanism of communication between CDI Specialists/Coders and physicians to clarify ambiguous, incomplete or conflicting documentation in the medical record.

Concurrent Query: A concurrent query is defined as one that is initiated before the patient has been discharged from the facility.

Retrospective Query: 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.