Over the past fifteen years, there has been an increased focus on clinical documentation and provider inquiries in the outpatient (OP) healthcare setting. There are similarities to the inpatient querying process, however today, in the outpatient area there is often more emphasis on diagnosis documentation and medical coding, primarily due to the increase in Risk Adjustment, or Medicare Advantage. Ensuring that the documentation is complete, thorough, accurate and compliant is always the focus and a goal with OP querying no matter if it is in regard to a procedure, treatment, past history or a current diagnosis.
Clinical documentation integrity (CDI) in the outpatient setting can mean Emergency Room encounters, Outpatient Surgery, Hospital Observation, Hospital ancillary encounters (i.e., OP Physical Therapy, Infusion), Physician Office, Clinic setting, etc. Although for the outpatient setting there can be a variety of documentation query considerations generated from CDI and Coding staff; ICD-10-CM (diagnosis), CPT, and HCPCS codes. The following maybe some specific areas to focus on:
- Diagnosis (HCCs) and/or Medical Necessity (Hospital and Physician)
- CPT E&M (facility-based, often via EHR)
- CPT ER Procedures (Hospital and Physician)
- CPT ER I&I (Injections/Infusions) – Hospital
- Diagnosis and CPT I&I Chemotherapy; Radiation Oncology
- Outpatient Surgery: Diagnosis and Surgery/Treatment (CPT); Endoscopy
- Ancillary Services: Diagnosis, CPT (Charge Capture)
- Skilled Nursing and/or Rehab: Diagnosis
- Dialysis Centers: Diagnosis and Treatment
The Outpatient Querying Process goals should be clearly stated and understood by CDI and Coding staff; here are a few examples of OP CDI and/or Coding goals:
- Identify and clarify missing, conflicting, or nonspecific provider documentation related to diagnoses AND procedures;
- Support accurate diagnostic and procedural (CPT) coding, leading to appropriate and compliant reimbursement;
- Promote health record completion during the patient’s course of care, which promotes patient safety and quality.
Per the AHIMA Outpatient Query Toolkit, Queries will be initiated as a result of identified documentation gaps. Queries may be required in situations such as:
- Documentation that is conflicting, contrasting, imprecise, incomplete, illegible, ambiguous,
- or inconsistent
- Clinical indicators of a diagnosis, but no documentation of the condition
- Only the treatment is documented without a diagnosis documented (e.g., Lisinopril documented as a refill medication, but no documentation of hypertension)
- Clinical evidence for a higher degree of specificity or severity
- Uncertainty of a cause-and-effect relationship (e.g., urinary tract infection with a urinary catheter)
- When it appears, a documented diagnosis is not clinically validated
- Present on admission indicator status (e.g., in the ED/observation setting, in the event the patient gets admitted as an inpatient)
- An order for test or procedure without further documentation in the record or plan of treatment
A variety of queries may be needed in the outpatient setting depending on the service line. For example, if the setting is outpatient surgery in the endoscopy suite, then a clarification query regarding a “Screening Versus Diagnostic Colonoscopy” might be indicated. Also, in outpatient surgery, a documentation query may be indicated regarding the type of “Device Used or Inserted;” Or in a physician office setting, a query for clarification of “Documentation of Medication with No Associated Chronic Condition.” In the hospital observation setting, you may need to query for clarification regarding the “Cause and Effect” relationship of two diagnostic conditions. Another example of when you might need to query, is for “Clarification of a Diagnosis Listed as a History but Maintained on the Home Medication List.” Capturing accurate diagnoses is a main component that drives the Risk Adjustment Hierarchical Condition Categories (HCCs), so we see across healthcare an emphasis in this specific area for clinical documentation querying.
There also must be a written policy and procedure (P&P) to support your outpatient query process; address the who, what, where, when, why and how. Once the P&P is written and in place, orient and educate your staff to ensure they have a clear understanding or the expectation and process. In addition, be sure to make your provider community aware and engaged in documentation querying as much as possible.
The compliant documentation query must follow the industry standard published by AHIMA and ACDIS with the 2022 Practice Brief, “Guidelines for Achieving a Compliant Query Practice”. The industry gold standard is to follow, refer to, and adhere to this document often as not only a guide but also as guidance for compliant querying. The documentation query (clarification) should NOT, should NEVER lead or promote any particular diagnosis or procedure. We are all busy and it doesn’t slow down, but there is always time to do your querying correctly and compliantly.
References: AHIMA/ACDIS AHIMA Outpatient Query Tool Kit; AHIMA; AHIMA/ACDIS 2022 Practice Brief: Guidelines for Achieving a Compliant Query Practice; Outpatient Clinical Documentation Improvement . . . Achieving a Successful Program (Part II) – MRA | #1 Provider of Coding Auditing Cancer Registry Services (mrahis.com); info@Pinsonandtang.com; https://acdis.org/resources/guidelines-achieving-compliant-query-practice%E2%80%942022-update