Within Clinical Documentation Integrity (CDI) and clinical Coding we have verbal, written and electronic documentation clarifications or querying. A key component of the clinical documentation query is achieving and maintaining compliance. Having a written policy and procedure in place along with a formal quality review process for querying is thus essential and a must.
All across healthcare settings we see and read about clinical documentation which represents the condition(s) and history of the patient, the provider evaluation, management and services provided for a given encounter. The length and depth of this documentation must be compliant and tell the truth of the patient encounter. For Health Information Management (HIM), Coding and Clinical Documentation Integrity (CDI) professionals the attention to detailed clinical documentation is deeply embedded in their daily work. We all know and understand that the medical record documentation is vital to patient care, clinical outcomes, research, public health and reimbursement, so ensuring it is complete, accurate and truthful is a HIM, Coding and CDI imperative.
Did you know that a 2017 study of over 23,000 patient progress notes for one particular software showed that only 15% of the text was entered manually. The rest was either cut and pasted or “imported.” This tells us in HIM Coding and CDI that we need to be VERY careful when reading the medical record documentation and use caution as some information may have been brought forward from a previous encounter and may not be relevant to the current encounter.
The Office of Inspector General (OIG) has stated that “Good documentation is important to protect our programs. Accurate documentation ensures the Federal health care programs pay the right amount—not too much and not too little—to the right people.”
The Centers for Medicare and Medicare (CMS) considers medical claims to have insufficient documentation errors when the medical documentation submitted is inadequate to support payment for the services that were billed and paid, this results in a compliance risk and concern. Visit the following site for more information: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/CERTMedRecDoc-FactSheet-ICN909160.pdf
When the clinical documentation is incomplete, conflicting, contrasting or the information in the health record is ambiguous regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g., present on admission indicators), then we need to query the provider. We should query the provider if the documentation describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis or provides a diagnosis without underlying clinical validation.
A documentation query is a communication tool or process used to clarify clinical documentation in the health record for documentation integrity and accurate code (ICD-10-CM/PCS or CPT) assignment for an individual encounter in any healthcare setting.
The American Health Information Management Association (AHIMA) and the American Clinical Documentation Integrity Specialists (ACDIS) brought a team of professionals together and developed an industry “Practice Brief” back in 2019. The title of this brief is “Guidelines for Achieving A Compliant Query Practice” and it has become a gold standard for documentation querying processes and for obtaining query compliance. Any and all who oversee, conduct, or review querying should have this document as a primary resource and tool. You can access this document at: https://bok.ahima.org/doc?oid=302673#.YlmPt4vMJpk
Per the Practice Brief, “All queries, including verbal queries, should be memorialized to demonstrate compliance with all query requirements to validate the essence of the query (see below). Regardless of how the query is communicated, it needs to meet all of the following criteria:
- Be clear and concise
- Contain clinical indicators from the health record
- Present only the facts identifying why the clarification is required
- Be compliant with the practices outlined in this brief
- Never include impact on reimbursement or quality measures
Examples of noncompliant queries include but are not limited to (some of these are from the Practice Brief):
- Directing a provider to document a diagnosis that is not clinically supported but serves as an exclusion for a patient safety indicator;
- Adding a non-reportable diagnosis;
- Encouraging a provider to neutralize documentation suggestive of a post-surgical complication;
- Including reimbursement or financial information in the query;
- Offering awards or gift (monetary or otherwise) for documenting a specific diagnosis or condition;
- Querying the provider on encounters in a non-timely manner (i.e., months or years later);
- Pressuring the providers to document a specific diagnosis, condition or procedure that is not supported by the encounter;
- Over-escalating unanswered queries to other providers and other leadership creating situations of perceived coercion.
Another great resource to utilize when striving for query compliance is the AHIMA Practice Brief, “Ethical Standards for Clinical Documentation Integrity Professionals, 2020. This is available at: https://www.ahima.org/media/r2gmhlop/ethical-standards-for-clinical-documentation-integrity-cdi-professionals-2020.pdf?oid=301868
Awareness and education on and about the documentation query process is key for Coding, CDI and providers alike. Within any given facility, practice, institution or across a healthcare system there should be a formal query process in place and this includes having a quality review process also. In order to ensure and maintain query compliance, there needs to be a written policy and procedure for querying, for escalation of the query, for query retention and for a quality review.
The quality review process is essential but can be overlookedor forgotten. The query quality review (QQR) process will be similar to an auditing process which contains steps, processes and functions. In addition, the QQR is best if conducted on a frequent basis and certainly would include any new hires for CDI or Coding. These QQRs can be conducted internally or externally, often having both in place provides a great perspective to areas for improvement and reinforcement or even areas that need to be changed. The time is now to confirm your query compliance, do not wait for an investigation or negative issue to occur. Being proactive is better than being reactive!!
Visit the MRA website and access the online educational presentation on “Query Compliance” for more information and details.
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