Note from the Associate Editorial Director: Warning, avoid snarky query responses

by Melissa Varnavas

Recently, we received a question from a member about risk factors associated with providers not taking queries seriously and providing less than helpful responses. The question really goes to the heart of physician engagement.

Everyone has problematic physicians, or physicians who simply won’t play along with CDI efforts. Bringing those individuals into the CDI fold takes patience and persistence and typically includes a multi-pronged approach.

The first step, of course, is educating the provider community. This typically happens at program rollout but should also be a continuous process, so physicians understand any programmatic changes, shift in priorities, nuances in coding guidelines which alter documentation requirements, emerging trends in clinical definitions, and so on. Academic facilities often offer CDI information sessions to residencies. Some programs offer CDI basic sessions to any new provider during his or her onboarding processes. Many programs segment education by service line providing documentation education tailored to the diagnoses and procedures most problematic to that specialty.

Secondly, take that education to the next level by leveraging facility and physician-specific supportive data. This can be global physician query response rates, agree rates, disagree rates. Some redact the physicians’ names and show that breakdown by physician. For example, physician A has a query rate of 50%, agree rate of 98%, and disagree rate of 2% where physician B has a query rate of 75%, agree rate of 25%, and disagree rate of 75%. Clearly there’s a disconnect with physician B and showing that data will highlight to physician B that all his or her peers are responding more positively to CDI efforts. Break this down further and pull up a couple of redacted case examples of where physician B disagreed with the CDI query and what effect that had on the final reported code assignment and reimbursement outcomes. Remember, it is inappropriate to discuss financial outcomes with physicians on open cases. Queries should never contain CC/MCC or MS-DRG information. That said, physicians do need to understand the implications of their documentation related to facility and their own practice’s outcomes. If you can also show evaluation and management coding on a given case, even better, as that speaks to the physician’s own reimbursement.

Third, in tracking physician response data over time your program should be able to identify ongoing problematic physicians. At this point, the CDI physician advisor or program manager might approach the physician individually to provide additional education and work to identify barriers to compliance. Program directors should work with hospital administration to develop an escalation policy or any contractual obligations related to physician query responses. For example, the CDI director might meet with the chief medical officer to share salient data points on a monthly or quarterly basis and raise any physician response concerns at that time.

Finally, as past-ACDIS Advisory Board member Trey La Charité, MD, FACP, SFHM, CCS, CCDS, writes in The Physician Advisor’s Guide to Clinical Documentation Improvement sometimes you just need to ignore the incalcitrant. There are some physicians you’ll never be able to convince and at times it better to just move around these folks. Either they’ll come around or they’ll retire. Chapter 6 of this book outlines various aspects of physician engagement and is definitely a beneficial read.

In terms of negative results from physician non-compliance, of course, there’s always the immediate interpersonal/emotional response related to the interaction. CDI professionals on the receiving end of a “snarky” response may feel anger, frustration, or even fear if the physician is particularly aggressive in his or her response. It’s never okay to threaten or intimidate a colleague especially in the healthcare workspace and these types of responses should be handled seriously and involve human resources if necessary. CDI specialists on the receiving end of these responses may even feel pointless. In this case, teamwork and managerial support will be vital to prevent disenchantment of staff with their work. Even venting with colleagues at ACDIS can help individuals feel less isolated and see the humor in the situation. (Here is a link to an ACDIS Forum thread that should make you smile on “Stupid Query Responses.”)

There’s the financial effect as alluded to previously, too. Even one “snarky” response to an effective, and otherwise appropriate, query could result in a significant financial loss. Again, while programs should never place financial considerations at the forefront of CDI goals, monetary outcomes represent a significant CDI metric in terms of CC/MCC, CMI, and MS-DRG capture. Leverage this to your advantage in the next group education session. Pull up that snarky response and show the room what would have happened had the unnamed physician taken the time to respond appropriately.

Consider the CDI program goals related to clinical validation and denials management as well. Many CDI programs make their queries a permanent part of the medical record so “snarky” responses could put those records at an increased risk for a denial.

Don’t forget all the other efforts CDI affect from public reporting metrics, CMS pay-for-performance and value-based purchasing, population health initiatives, discharge orders, effective internal communications with other physicians, and wide-range of concerns stemming from the simple capture of the most accurate information in the medical record resulting from correct code assignment.

There is a ton of information on physician engagement available on the ACDIS site. Some of our most recent articles include:

• CDI Week 2019 Q&A: Physician engagement
• 2019 CDI Week Q&A: Physician Engagement: Sponsored by Nuance
• The May/June CDI Journal
• Chapter 2 of CDI Workbook: Investigating Complex Cases and Formulating Queries, by Sheila Duhon.

We hope you’ll be able to leverage some of these tactics and put responses such as “duh!” “ask someone else who has time for this,” or “it’s a no brainer” in the past.

Editor’s note: Varnavas is the associate editorial director of ACDIS. Contact her at mvarnavas@acdis.org.