Worksheet Review Process as
Agreed During Task Force
Meeting XX/XX/XXXX
Unanswered Queries:
If query is unanswered at the time of discharge, the CDS is to come to HIM and review the record to see if the physician has answered the question. If a review of the record indicates that the question has not been answered, the chart will proceed to be coded. If, at the time of coding there the chart still needs clarification, the coder will generate a fax query form and contact the review nurse to pursue further follow-up with the physician.
The review nurse will contact the physician’s office by phone to notify them that a fax query is being sent and requesting a prompt reply.
If the fax query is returned within 48 hours to the designated coder, the coder will return the query to the principal coder for completion. A designated coder will notify the review nurse via e-mail that a response was obtained. If the nurse is not notified within 48 hours that a reply was received, she can assume that no response was obtained.
If no response is received within 48 hours (business days), the chart will then be referred to the CDI Physician Advisor for follow-up who will contact the physician in question. The physician will then have 72 hours (business days) to respond. If no response is obtained after 72 hours and a query response would result in > $500 (RW change of .10) in revenue, the case will then be referred to the VP of Medical Affairs for further action.
If a response is still not obtained after 3 working days and the reimbursement potential is ≥ $10,000, the case will then be escalated to the CEO for further action, as determined.
General Communication:
If there is a discrepancy between the CDS’ and the coder’s interpretation of the medical record, resulting in the assignment of a lower-weighted DRG (change in PDx, omission of a MCC/CC, alternate procedure), a discussion will take place between the coder and the CDS, at a time arranged via phone, e-mail, or page.
If, after discussion, consensus is still not reached, the chart will be referred to the CDI Physician Advisor for review and the coding manager will be notified by the coder of such cases (so as to account for all uncoded charts).
If, during or after coding a record, the coder identifies the need to query the physician, the coder will contact one of the CDS to initiate the above “unanswered query process” to obtain further clarification. If the need for a MCC/CC or capture of the appropriate SOI/ROM remains after the DRG analyst has analyzed the chart, and querying the physician might result in increased reimbursement or SOI/ROM, the CDS will be contacted to initiate the “unanswered query process” above to obtain further clarification.
The coding summary sheet, which is to be attached to all CDS worksheets, will be notated by the coder in the lower corner or the summary sheet as follows:
“CDS” if a CDS worksheet was generated for that record
“PA” if the CDI Physician Advisor reviewed the record
“DRG” if the record went to the DRG analyst for additional review
General Guidelines for consulting the CDI Physician Advisor
- if consensus is not reached between the coder and the nurse and such analysis would result in additional reimbursement of ≥ $500.00 or greater SOI/ROM.
- when an immediate clinical decision is needed after the CDS are gone for the day, or on the weekend. In these cases, the CDS will be notified of such action via e-mail or voice mail.
- All cases reviewed by the CDI Physician Advisor will be noted (as above) on the coding summary worksheet or, if no summary sheet is attached, on the CDI worksheet, so that a record may be kept for tracking and quality purposes.