Q&A: Determining what constitutes a leading query

A: I am unaware of any organization or agency routinely monitoring physician queries. However, regular query review for compliance with existing industry guidelines, reflection of appropriate clinical indicators, and application of accurate coding guidelines and regulations should be part of your ongoing CDI program efforts and/or your organization’s regular compliance reviews.

 

Leading queries are typically identified during an external audit or Office of the Inspector General (OIG) investigation where the billing practices of an organization are investigated. The ramifications of such investigations may lead so far as accusations of false claims violations and/or fraud as was described during the 2012 ACDIS annual conference presentation "Medicare Claims Recoupment: Case Study of Department of Justice Settlement.” 

 

Anecdotally, some facilities have reported Recovery Auditors denying claims on the basis of a supposed “leading” query (read a related article in the October edition of the CDI Journal). However, the term “leading” can be somewhat ambiguous. I typically teach that a leading query is one that forces the provider to a particular conclusion—where the CDI specialist basically tells the provider what to document and/or how to document a particular condition. 

 

Without an official description from CMS of “leading,” it is subjective as some may consider a query leading where others may not. When in doubt, refer to the existing guidance from AHIMA including:

ACDIS and AHIMA are currently working on a joint physician query guidance report which is expected to be released in 2013.

 

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., answered this question. Contact her at cericson@hcpro.com.