Q&A: Anyone on the care team can answer a query and be compliant

Q: For some reason, I was under the impression that a query could be answered by any healthcare provider, even one just doing a review of the case (a fellow hospitalist, for instance). I know that a treatment provider is, of course, the way to go but was wondering about this as an option for getting the query completed and if we do go this route if the record would be able to stand up to a Recovery Audit review.

A: Any member of the treating medical team can answer a query (not just the attending physician) as long as the documentation does not conflict with that of the attending provider. Coding can occur based on the documentation of any licensed independent practitioner (NP, PA, MD, DO or resident), who provides direct treatment.

CDI specialists may leave queries in the medical record addressed to the medical team rather than a particular provider to ensure a timely response as the attending physician may not be making rounds the day the query is issued.

The exception may be electronic medical records that require the query to be addressed to a particular person in which case, it would probably go to the attending, but if possible would be copied to all members of the treating medical team. I previously worked at an academic medical center and we never had a problem with any member of the treating medical team addressing a query.

With that said, the attending physician is ultimately responsible for the medical record, which is why some CDI programs address their queries directly to that individual. But I don’t know of any guidance that says queries can only be issued to the attending physician. The only exception is if there is conflicting documentation in the medical record. In that case the attending physician must provide final clarification.

I think it is also important to address the role of the CDI/UR/CM physician advisor in health record documentation. Although a physician advisor is a practitioner, who can provide direct patient care under the scope of their licensing, it is inappropriate for them to document within the medical record unless they are part of the treating medical team e.g., if the patient is under their care and they are assuming/sharing responsibility for the care of the patient.

In other words, when the physician advisor is responsible for the care/treatment of a patient they can use their knowledge of CDI to ensure accurate documentation within the medical record; however, it is inappropriate for the physician advisor to document in the medical record/answer queries when they are not involved in the care of the particular patient. Documentation under these circumstances can be viewed as fraudulent because it appears the health record is being modified for the purpose of reimbursement or some other outcome metric rather than as part of patient care.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, answered this question. At the time of this article's original release, she was the CDI Education Director for HCPro Inc.