Get back to query basics

The American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Improvement Specialists (ACDIS) released joint physician query instructions in Guidelines for Achieving a Compliant Query Practice in February 2013.

Nevertheless, a lot of myths and misinformation about query practices still remain, says Cheryl Ericson, MS, RN, CCDS, CDIP, CDI education director for HCPro, a division of BLR, in Danvers, Massachusetts.

Coders and CDI specialists must query for the right reasons, says William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Florida. "Above all, we should remain intellectually honest. Don't lead the doctor to document a condition that you know is not clinically significant."

AHIMA, along with CMS, the American Hospital Association (AHA), and the National Center for Health Statistics, comprise the four Cooperating Parties in charge of ICD-9-CM code creation and updates. They will continue this role for ICD-10-CM/PCS.

Any advice from these governing bodies bears additional regulatory weight. Coders and CDI specialists should also regularly review advice from ACDIS, which is the only national association solely dedicated to CDI. That said, coders and CDI specialists need to remember the hierarchy to follow in terms of coding and querying advice, Ericson says.

The Official Guidelines for Coding and Reporting and AHA Coding Clinic for ICD-9-CM (now Coding Clinic for ICD-10-CM/PCS) each include guidelines for when to query physicians. For example, the Official Guidelines for Coding and Reporting state:

A joint effort between the healthcare provider and the coding professional is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized.

Refer to the Official Guidelines for Coding and Reporting first, then to Coding Clinic, for applicable recommendations regarding specific diagnoses and query advice. These two related publications often provide specific instances of when query submission and clarifications may be warranted. For example, the Official Guidelines for Coding and Reporting recommend querying to determine whether:

• A pressure ulcer is new or healing
• A condition such as sepsis or a potential hospital-acquired condition was present at the time of admission
• An abnormal finding should be added to the diagnostic statement and coded

Coding Clinic does not provide clinical criteria for establishing diagnoses, says Nelly Leon-Chisen, RHIA, director of coding and classification for AHA in Chicago. Instead, it provides clinical "clues," she says. In addition, Coding Clinic has no authority to provide clinical definitions.

Coding Clinic also does not replace physician documentation regarding the clinical significance of a patient's condition, Leon-Chisen says. "We have periodically provided information on the type of documentation that can be used for coding." Coding should be supported by the physician documentation, she notes. "Coding Clinic is not a substitute for the physician's clinical judgment."

When CMS rolled out MS-DRGs in 2007, the agency essentially gave facilities the green light to expand CDI efforts. The August 2007 Federal Register encourages facilities to better capture clinical documentation to improve coding opportunities. It states:

We do not believe there is anything inappropriate, unethical, or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.

Additionally, CMS has said through TMF Quality Institute, its Quality Improvement Organization for Texas, that queries are acceptable as long as they:

• Are not leading
• Do not introduce new information not otherwise contained in the medical record
• Provide clarification
• Are consistent with other medical record documentation

"Unfortunately, CMS did not define what it ­considers 'leading' nor what is considered as 'introducing new information,' which has left much open to interpretation," Ericson says. Instead, CMS left it up to industry associations such as AHIMA and ACDIS to fill in the gaps.

New rules differ from old rules
Earlier practice briefs did much to outline when queries might be necessary, such as:

• Clarifying conflicting, incomplete, or ambiguous documentation
• Situations such as illegibility, incompleteness, lack of clarity, inconsistency, or imprecision

However, the definition of what constitutes a "leading" query remained ambiguous until 2013. The brief finally addressed this concern directly by stating:

A leading query is one that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or procedure. The justification (i.e., inclusion of relevant clinical indicators) for the query is more important than the query format.

"That's one of the nice things about the 2013 brief, that we finally have a definition of 'leading,' " says Ericson, who points to CMS' original statement regarding query creation. "It says that the query is okay if it is consistent with other medical record documentation, and that's what the latest practice brief says also."

Similarly, the 2013 release builds on AHIMA's previous publications and guidance. Yet some professionals adhere to earlier recommendations and neglect advice contained in the new brief.

For example, previous recommendations limited the use of yes/no queries (where the physician was allowed to answer either yes or no) to questions pertaining to whether a condition was present on admission. The updated guidance allows such questions in additional specific circumstances with the addition of options for "other," "clinically undetermined," or "not clinically relevant," Ericson says.

The guidance also outlines that yes/no queries should not be used if the physician hasn't yet documented a diagnosis in the record.

The brief states a yes/no query can be used in the following additional circumstances:

• Substantiating or further specifying a diagnosis already present in the health record (i.e., findings in pathology, radiology, and other diagnostic reports) with interpretation by a physician
• Establishing a cause-and-effect relationship between documented conditions such as manifestation/etiology, complications, and conditions/diagnostic findings (i.e., hypertension and congestive heart failure, diabetes mellitus and chronic kidney disease)
• Resolving conflicting documentation from multiple practitioners

The 2013 guidance highlights different query format options-open-ended, multiple-choice, and yes/no-as well as differences between written and verbal queries with scenarios outlining each one's appropriate use. The format choice needs to reflect the clinical scenario and information available-the context of the situation, Ericson says.

Editor’s note: This article was originally published in the March issue of Briefings on Coding Compliance Strategies.