Book excerpt: Peer review to ensure compliant query practices

By Marion Kruse, BSN, RN, MBA, and Jennifer Cavagnac, CCDS

Every CDI program should objectively evaluate the outcomes, processes, and compliance of their CDI efforts. Auditing and monitoring provides oversight for the CDI program, insight into physician documentation and collaboration, and objective evaluation of the performance and effectiveness of individual CDI staff members as measured against your facility’s policies and priorities.

According to AHIMA’s “Managing an Effective Query Process” “Healthcare entities should consider establishing an auditing and monitoring program as a means to improve their query processes.”

Facilities that rely too heavily on consultants (or those who rely on consultants without overseeing their methods) may find their programs under government scrutiny. As the adage goes, “ignorance of the law is no excuse.” If inappropriate practices and inaccurate data are promulgated, it is the facility’s responsibility to investigate the processes that led to the inaccuracies and to apply corrective actions.

CDI managers will need to decide which queries to review and how to track the analysis. In many situations, a simple Excel^® spreadsheet can do the trick, although many facilities rely on electronic query systems or vendors to supply the raw data.

To create a statistically valid audit, you’ll need to pull a reasonably wide selection of queries to review. For example, to figure out how frequently clinical indicators are used on queries, pull five charts from each staff member. Based on ACDIS benchmarking surveys, a monthly volume of 150 to 250 new cases and a query rate of 20% provide 30 to 50 queried cases. If a 10% random review rate is established as a goal, then five cases per CDI specialist per month should represent a reasonable audit plan. Choose five queries from five cases or days at random. This protects your review and the staff member from the risk that an outlier event (e.g., an unexpected illness or ill temper) will skew overall findings

Audits need not be a strictly managerial effort. Peer-to-peer reviews can provide an opportunity for CDI staff members to learn from each other, to see what each other is doing and support process improvement.

In summary, a successful CDI program and physician query process involves bringing together the knowledge of many individuals with various training and expertise. It requires thorough and consistent review of ongoing trends within healthcare regulatory and reimbursement realms. An effective query practice requires not only the review of industry guidance but also the incorporation of that guidance within the CDI department’s policies and procedures.

Furthermore, the expertise of each individual within the healthcare processes—from coder, to physician advisor, to CDI specialist—offers an invaluable insight as to how to craft compliant, clinically relevant query. Team involvement is crucial for the immediate and ongoing success of the program. Building a strong sense of teamwork through establishment of a vision, goals, and recognition will allow the hospital to leverage this knowledge and build a program that functions at the highest level with the greatest rate of return.

Editor’s note: This is an excerpt from The Essential Guide to Provider Queries by Marion Kruse, BSN, RN, MBA, and Jennifer Cavagnac, CCDS.