Disconnect between staff and compliance practices

It has been three years since ACDIS last surveyed its membership about physician query practices. In 2010, 382 CDI professionals participated. This year’s survey garnered 517 respondents, primarily CDI specialists.

 “That’s really a tremendous response rate,” says Drew K. Siegel, MD, CPC, CDI specialist at the University of North Carolina (UNC) Hospitals in Chapel Hill.

The 35-question survey illustrates the importance of the physician query as the primary tool driving CDI efforts, but also demonstrates wide differences regarding query assessment, compliance, and policy review.

“The responses are actually quite varied, so there’s evidence that the query process [across facilities] is clearly not standardized,” says ACDIS Advisory Board member Timothy N. Brundage, MD, CCDS, physician champion at Kindred Hospital North Florida District in St. Petersburg.

That said, the 2013 survey does show some interesting trends, according to fellow ACDIS Advisory Board member Walter Houlihan, MBA, RHIA, CCS, CDI specialist at Baystate Health in Springfield, Mass.

“It is good to know that so many of us have the same challenges and needs when it comes to physician queries,” he says.

 Query process
Most respondents (97.9%) perform queries concurrently and more than half (55.9%) perform retrospective queries prior to billing. Most (60%) say they review records daily. The slightly increased emphasis on daily record review (up 2% from 58% in the previous survey) may illustrate facilities’ attempts to reduce patients’ length of stay (LOS).

“We used to really only look at the records at the time of admission,” says Sharin L. Cancilla, RHIT, CCDS, CDI specialist at Botsford Hospital in Farmington Hills, Mich. Now, with a team of six CDI specialists, Cancilla’s facility reviews records daily.

“In the past there wasn’t the urgency to look at the records daily,” says ACDIS Advisory Board member Dee Banet, RN, BSN, CCDS, CDI director at Norton Healthcare in Louisville, Ky. “But as the LOS decreases, the time staff has to look at the chart decreases too, and with it your window of opportunity.”

Outstanding queries are closed out by either the HIM/ coding department (41%) or the CDI department (48.7%), according to the survey. This may be indicative of those who conduct retrospective reviews, says Cancilla.

“Our CDI staff members handle any outstanding queries that remain on the charts after the patient is discharged,” she says. “But the coders may catch something we missed. If that happens, they would query the physician and follow up that query. We work hand in hand with our coding/HIM team and that’s the best way to be.”

“All of these responses seem pretty indicative of best practices,” says Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP, HIT Pro-CP, MCP, CDI specialist at TrustHCS in Hyattsville, Md. Concurrent review is “really what CDI specialists do,” he says, adding that the growth of retrospective queries is an interesting expansion of CDI specialists’ responsibilities.

Written, verbal, or electronic Respondents indicated that the majority of their queries are written—either paper or electronic (78.5%). Although only 5.2% indicated the majority of their queries are verbal, most (36.4%) indicated that verbal conversations and discussions are the most effective techniques they use.

“It is good to see that the industry still recognizes the importance of that verbal face-to-face interaction,” says Banet.

The fact that so few respondents conduct verbal queries while so many indicate that verbal interactions are the most effective query method could mean CDI specialists follow up verbal efforts with written query forms, or as some respondents indicated, use a combination of verbal and written practices.

“That is in line with what we do,” says Dominesey. “We follow up that verbal interaction with a written query. If you are talking with the physician and he agrees with you and everything seems fine, nine times out of 10 he forgets to go back and document the necessary language in the medical record. So you need that one-on-one verbal interaction to build camaraderie and provide education, but you also need that written component.”

As part of an academic medical center, Siegel says the CDI team rounds with the physicians and relies heavily on verbal queries. They only use written forms when physicians are unavailable or neglect to provide a response in the medical record. However, UNC is in the midst of transitioning to Epic, an electronic health record (EHR) system, Siegel says, and query efforts could change dramatically.

Electronic query systems
The number of facilities with electronic query systems is increasing dramatically, with 43.5% saying they use one— up from 33% in 2010—and another 17.6% indicating they are in the process of implementing one. However, experts warn to not view the EHR as a panacea.

“Electronic records do not solve documentation problems,” says Dominesey. Although many systems provide drop-down menus aimed at clarifying typical documentation missteps, CDI professionals still need to ensure that these do not lead the physician to inaccurate or inappropriate documentation.

CDI specialists also need to review records to help guard against physicians who copy and paste patient conditions from one day to the next. Of those who have electronic query programs, only 25.5% indicate it includes auditing and reporting capabilities. The survey shows similarly low responses (between 20% and 30%) regarding the efficacy of e-queries.

 “Those numbers are really low,” says Banet. “These are really areas where the electronic systems can work for us. These results might be indicative of those who are struggling with adapting to the change, or it might represent those who feel frustration that the system simply isn’t helping.”

Cancilla’s program continues to run on a hybrid model—part paper, part electronic. Nevertheless, with the government’s push for electronic records and meaningful use, she says she was “sort of surprised that more programs don’t have electronic queries in place.”

 Less than 50% of respondents indicated that their electronic query system includes query templates. “Some provide the capability [for template use] if facilities ask for them, but most will ask the facility to provide the templates themselves,” says Dominesey.

Facilities should work with coders and physicians by specialty to ensure buy-in, accuracy, and compliance when implementing electronic systems as well as creating query templates, he says.

The survey shows that “opportunities still exist in changing over to the electronic processes and thereby improving efficiencies of our CDI and physician communications,” says Houlihan.

Template use
Nearly all CDI programs use query templates. Most, 64.8%, say they used association guidance to help develop their temples, followed by 45.4% who obtained guidance from consultants and 22.6% who included coding manual information.

Although 87.1% of respondents indicate they follow AHIMA guidance, only 59% say they follow it fully, and 8.9% say they do not know or have not read the latest information. Another 3.9% say they have separate query policies for CDI and coding staff.

 “Given the collaboration between ACDIS and AHIMA [throughout the various query practice briefs], I am a little concerned by that 3.9% and 8.9%,” says Houlihan. “We feel the guidance should be used by everyone.”

 When asked which staff members were involved in query template creation, not surprisingly, most said CDI staff and managers, HIM/coding staff, and physician advisors.

Query policies
Survey analysts were troubled to see that only 60.5% of respondents have established query policies and procedures, with 10% stating they only have policies that apply to written queries and 6.6% with policies and procedures that only apply to coding staff.

“That’s concerning,” says Houlihan. “If you have a practice, you should have a policy to back that up,” says Dominesey.

Siegel, however, suggests that perhaps there is a lack of awareness of CDI policies by those who actually perform the role (though this is also a concern).

“It depends on how involved [CDI staff members] are with management efforts,” he says, suggesting that policies may be in place but the staff members themselves may not have been involved in their development and therefore have limited awareness of them.

Similarly, when asked which staff members were involved in creating query policies, only 53.3% indicated that the CDI department participated.

Although that was the highest response, it is still only half the response one might hope to see, Brundage says. “If their role is to be CDI specialists, they need to be better informed about the standards they operate under,” Brundage says. “They cannot just leave it to the manager, and managers need to educate their staff about what policies are in place and why.”

Query permanence
 Only 32.9% of respondents keep physician queries as a permanent part of the patient medical record, and 26.1% indicate they never submit queries to auditors, although the plurality (30.5%) did not know whether their queries could end up in front of an auditor for review.

“I think there is some confusion around this issue industry wide,” says Siegel. “The trend is that Recovery Auditors are looking for queries to see if they are leading or not. If programs do not have policies regarding whether they keep and submit queries, they should develop them.”

That CDI specialists did not know about auditor activity did not surprise Dominesey, however.

“Really, a lot of CDI specialists simply are not involved in denials management or audit review. You can argue that point—as to whether they should be involved or not—but that’s just what this survey illustrates,” he says.

Auditing and monitoring query efforts
 You can determine whether your queries are compliant by breaking them down into their component elements, says Banet.

 In terms of which elements programs monitor, 91.1% monitor the name of the physician, 80% the name of the CDI staff member submitting the query, 71.6% the department that originated the query, and 66.9% the method of delivery. To determine the success of the query process, 70.6% track the final DRG, 69.9% track the financial impact of the query, and 69.1% track whether the response to the query was positive or negative. Most respondents, 56.1%, also monitor for leading queries, missed query opportunities, 52%, and clinical support, 46.8%.

The measures are “all pretty standard, although one might assume that some of those elements should be at 100%. Shouldn’t 100% of programs be keeping track of who originates the query and who is receiving the query?” says Siegel.

Nevertheless, Houlihan says, “it is good to see that respondents are using various indicators to monitor query performance.”

The plurality of programs, 31.7%, only review their query forms on an as-needed basis.

This makes sense, Banet says. Although most programs aim to annually review query templates, in reality most forms only need updating when accepted clinical indicators change, new industry query guidance is published, or significant coding changes occur.

“It can be one of those things that gets pushed to the bottom of the to-do list,” she says.

Priorities and productivity
 Most respondents (67.3%) say their CDI program prioritizes queries for any record that requires clarification regardless of impact. Similarly, 45.5% say they “always” query for clarity, completeness, severity, etc., when the query does not affect reimbursement, and 42.7% say they “frequently” do so.

CDI staff members typically review six to 20 records per day (83%)—with similar responses on the number of re-reviews—resulting in 11%–30% of the charts with query opportunities, according to 51% of survey respondents.

“This is a really hard one to nail down,” Cancilla says. “Some days you could ask queries on all six records you’ve reviewed and some days there won’t be any query opportunities.”

Most programs avoid setting a query quota, which is good news, but “it is concerning to see that 32.7% have a set quota CDI staff are expected to meet,” Houlihan says.  “Hopefully this does not negatively affect the quality of the queries submitted to physicians and that CDI staff are not simply submitting a query just to meet that quota.”

 Yet 42% say their facility expects them to query on 11%–40% of their charts and 11% say they query on more than 50% of the charts. When asked what percentage of cases reviewed have one or more queries posed, 33.4% say between 11% and 25%.

“Typically about 30% of the records have some query opportunity,” says Dominesey, who expects that to increase to 50%–60% come ICD-10-CM/PCS implementation.

 However, “nailing down these numbers can be difficult, and the survey sort of illustrates that,” says Banet. “Every role is unique, and processes differ according to what expectations are. The number of records a CDI professional can review will be less if they also have case management or quality duties.”

Most respondents reported fairly high physician response rates—77.7% say physician response rate is greater than 70%—and moderate physician agreement rates—only 32.1% say physicians agree to more than 90% of queries.

“It is good to see the high percentage of physicians responding to queries across the board,” says Houlihan. “The high percentage of physicians agreeing with the queries can either demonstrate that the quality of the queries is good or that the physicians are just agreeing with the query to get it off their plate.”

Agreement rates should be higher than 70% but not as high as 100%, agrees Dominesey, and the survey seems to bear that out. Finally, although nearly 40% of respondents indicate that they leave fewer queries as the program matures, that number is lower than in 2010.

“It is promising,” says Cancilla, who adds that she rarely needs to ask physicians to specify systolic or diastolic heart failure any more, yet continues to query for stage of kidney disease. But she does not foresee the need for queries lessening in the future.

“There will always be new diagnoses that need clarifying and new physicians joining the facility, never mind new coding rules and regulations, new government reimbursement initiatives that target different documentation areas, and ICD-10. There will always be room for CDI to expand, always be a reason for a query of some sort,” she says.

Editor's Note: The 2013 Physician Query Benchmarking Report is available to ACDIS members in its entirety in the July CDI Journal .