Audits, education, and collaboration are key to reducing query rates

While some providers may decide to tackle documentation and coding challenges through coder and physician education alone, the audit piece is perhaps just as important, since delayed claims submission due to physician queries directly affects cash flow and, therefore, a hospital's operating income.

"We want to be proactive by submitting accurate claims and receiving reimbursement in a timely manner in order to maintain all hospital operations," says Gwen S. Regenwether, BSN, RN, a clinical documentation specialist at Denver Health and Hospital Authority, a 525-bed hospital. While this can, admittedly, be a frustrating and time-consuming process, identifying financial vulnerabilities by taking a proactive approach is necessary to minimize any financial disruption due to the transition to ICD-10-CM/PCS.

"We assessed our procedure documentation prior to ICD-10 implementation, provided education to our surgical staff, and evaluated our financial risk pre- and post-educational intervention," Regenwether says.

Denver Health's CDI team, which consists of five CDI nurses and one business analyst, started by conducting monthly audits, and then they transitioned to quarterly audits. Incidentally, their CDI team works closely with one physician director and three physician advisors (i.e., hospitalists).

"Our hybrid medical record is, by far, our biggest challenge that we work with daily," says Cheree A. Lueck, BSN, RN, a former clinical nurse and a current clinical documentation specialist at Denver Health. Physician documentation (e.g., history and physical, progress notes, consults, and admissions) at the facility, which admitted 25,000 inpatients in 2014, is done completely on paper, which is then scanned into their electronic records. In addition to challenges that result from illegible physician handwriting, Lueck notes that it is time-consuming and difficult to extract data from the facility's hybrid system.

"Our nursing and ancillary staff document on computers, and we then sift through both the paper and electronic records," Lueck says. "But during our auditing process and surgical education, we came to learn about another quagmire to our current system."

When residents dictate their operative notes, they are not able to go back and proofread them or make any changes. That can only be done by the attending physician, which represents yet another extra step for surgical attendings?especially considering Denver Health's large and frequently rotating resident population.

o assess its documentation, Denver Health conducted a baseline audit over the course of four months starting in April 2014. The facility looked at operative procedures for eight surgical specialties to evaluate exactly how many ICD-10-PCS queries would be initiated with its current level of documentation. After completing the audits and compiling the results, Denver Health gave an educational presentation to the director of each surgical specialty.

"These meetings included education on ICD-10-PCS (what it is, how it is structured), and we also provided their individual subspecialty results with specific educational feedback for their department," says Regenwether.

Audits conducted during August and September 2014 gave the CDI team time to provide individual feedback to specific physicians and reinforce their education. From October through December 2014, audits conducted were performance-based and part of an incentive program for physician compensation, accounting for up to 2% of physicians' bonuses.

"Once these audits were completed, we were able to compile our data and evaluate our query rate and financial impact post-intervention," Regenwether says.

To identify the facility's query rate, the CDI team conducted manual audits and coded records using actual documentation for operative procedures to determine where documentation was sufficient and where they were unable to code all seven ICD-10-PCS characters.

They conducted retrospective audits for 37 general surgery operative reports, for example. Out of this sample, 74% of the reports could be coded, and 26% could not be coded without further clarification from the physician. Therefore, Denver Health had a 26% query rate for general surgery.

"This query rate demonstrated the potential impact our facility is at risk for if we did not provide any education for our physicians and proceeded with ICD-10," Regenwether says. "A query rate of 26% demonstrated to us that physician education and procedure documentation is a necessity."

The average query rate for all eight surgical specialties combined was 23%. This baseline query rate reflects the percentage of claims that would be held up due to queries if ICD-10 had been implemented prior to their intervention.

Anything that delays claims submission quickly affects cash flow. For example, for the second quarter of 2014, surgical cases accounted for $115 million of the $192 million in hospital inpatient facility claims. The eight surgical specialties audited would have accounted for $85 million in claims for that quarter out of the $115 million. At the baseline query rate of 23% for all surgical specialties, claims for $19 million in facility charges would have been delayed due to uncodable operative reports in that quarter, says Regenwether. "This would have a significant impact on our hospital's operating income," she says.

Editor's Note: This article is an excerpt from Briefings on Coding Compliance Strategies.