From the Forum: What to do when a noncompliant query’s discovered

Q: During a final pre-bill coding review, the coding leader identifies a CDI initiated query that does not meet the ACDIS/AHIMA guidelines for a compliant query. But, the physician has already responded to the query with a diagnosis which was then used during the coding process. To make things more complicated, the physician only noted the response on the query itself and not in the progress notes.

What steps should the coding leaders take after the noncompliant query is identified? Does the query stay in the medical record? Or, should we send another query to the physician with an explanation for the duplicate query? What do we do with the diagnosis that the physician has noted on the query?

A: If it were me, I’d consult with the compliance department and respond accordingly. Several things occur to me though. First, the coders should be educated on how to recognize a noncompliant query and when to refer something to management rather than coding the condition, no questions asked. Secondly, education should also be provided to the CDI specialist who initiated the noncompliant query in the first place to stop the issue from coming up again.

As far as remaining in the record, the compliance department should be consulted. But, I would certainly remove the code assigned as a result of the query. Universally, I’ve been taught that one never alters or destroys any portion of a medical record. My instinct would be to leave it in the record as it was initiated and the physician has responded. I wouldn’t be comfortable at all removing the note.

That said, I would make an entry in the administrative portion of the chart (there is such an element) and make note that the condition was noted on a query, but not coded. I would personally take my loss, learn, and not query again for the same condition given that I would be leaving the first query and accompanying note in the record.

All Health Information Management (HIM) departments have a policy and procedure regarding corrections and edits to existing charts, and they should be consulted on this issue given that HIM is responsible for content of medical records and serves as the Custodian of Records for legal purposes. The steps I just provided were ones I have used as an HIM director in the past.

Editor’s note: Paul Evans, RHIA, CCDS, CCS, CCS-P, a staff member of a regional CDI program located on the west coast, and a member of the ACDIS Advisory Board, answered this question on the ACDIS Forum. To learn how to get involved on the ACDIS Forum and get your questions answered, click here.