Q&A: Handling CDI and coding query workflows

Q: We have a somewhat confusing scenario in our organization whereby the CDI team might have an open query and a coder then queries a different provider regarding a similar concern in order to expedite a response. Do other organizations work this way? Are there better workflow options or official recommendations related to CDI/coding collaboration?

A: CDI and coding departments should develop an internal policy that defines how long an open query, sent prior to discharge, is left open and who is responsible for closing it out after discharge. Many organizations establish policies whereby the CDI retains responsibility for concurrent queries through to 24 hours post-discharge with follow-up responsibilities falling to the coding team after that. Others have second-level CDI reviewers who follow-up on unanswered queries. Another option would be to have an escalation policy which calls for the intervention of a physician champion or advisor to follow-up with recalcitrant providers to impress upon them the importance of CDI efforts. 

Without a policy that clearly defines who closes out a query when unanswered and when is it okay to send another query in its place (or resend the original unanswered query), CDI specialists and coding professionals could be at odds. 

The 2019 ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice states:

“There may be times when a second query is needed to obtain further clarification of a previously answered query as additional information becomes available or as the clinical picture evolves. However, it is considered non-compliant to continue asking the same query to the same or multiple providers until a desired response is received.”

Let’s look at the following scenario:

• 2/1 ER: Patient is on home oxygen at 2 LPM via NC and has a documented diagnosis of chronic respiratory failure due to COPD.
• 2/3: CDI sends query for “acute” on chronic respiratory failure because the patient is on 4 LPM via NC during the admission and was symptomatic prior to oxygen administration which was clearly outlined in the documentation. 
• 2/4: Provider’s query response: acute/chronic respiratory failure.
• 2/5: As the underlying issue for the admission is resolved, the respiratory therapist begins weaning the oxygen to the patient’s prior oxygen baseline, however the patient fails to wean successfully, and the patient remains at 4 LPM oxygen.
• 2/6: The patient fails weaning again and remains on 4 LPM of oxygen.
• 2/6 Case management notes state: Called XYZ company to inform them that the patient’s lung disease has progressed per Dr. X, and the patient is now requiring 4 LPM of oxygen continuously. The company agreed to deliver new tank to the patient’s home on 2/7/22.
• 2/7 Discharge summary: The patient failed weaning of oxygen during admission and has increased oxygenation requirements due to a progression of COPD.  Case management has notified the device company and the patient is now requiring 4 LPM continuously being discharged on this new baseline oxygen level.

In this fictious scenario, new information documented on 2/5 states that the patient lung disease has progressed to a stage which now requires a higher amount of daily oxygen. The new information documented after the original query now requires a second query in attempt to rule out the acute portion of the diagnosis as the patient now has an increased home oxygen baseline for his/her chronic respiratory failure.

If the query went unanswered as described in the question, then a second query could still be needed if the new information in the medical record is significant.

Additionally, the above example can occur for any acute-on-chronic condition (or encephalopathy) if a query is sent before the patient starts to return to their prior baseline. Think about the acute kidney injury/chronic kidney disease (AKI/CKD) case in which it is determined that AKI isn’t actually present but that the increased lab values and patient symptoms are a result of the CKD progressing to the next stage. However, in most cases with this scenario, providers forget to rule out the acute portion of the condition which necessitates a second query (which could then be considered a clinical validation query).

When a query is pending and “resent” to a different provider because the treating physician is now off service, organizations need to establish a process or workflow for the new provider to receive notification of any unanswered queries. If such a process has not been established, confusion and duplication of efforts may arise. It could very well be that the coder needs to close out the query in order to submit the final bill. In that regard, the coding professional could be helping the CDI specialist get their query answered.

So, we’ve come full circle to the original issue which is not having a department policy to address who closes out pending queries after discharge. 

Without clearly defined departmental policies that encompass both CDI and coding departments, I’m afraid the two specialties will likely continue to run into these types of dilemmas. 

Here are some general questions to consider when determining a company policy on open queries:

• Who follows up on an unanswered query both concurrently and after discharge? 
• When does the CDI specialist’s responsibility end and the coder’s begin regarding open queries?
• If CDI sends a query that is not answered, what timeframe is considered appropriate to close the query? 
• Who is responsible for sending a second query for clarification if pertinent new information has been documented after the original query was submitted?
• Who is responsible for forwarding the unanswered original query when one provider is going off service and a new provider is coming on? 
• Who gets “credit” for the query on their metrics?

After exploring the two outlined possible rationales, we also need to be wary of potential compliance concerns. For example, was the original query answered and then someone sent another query because they didn’t like the answer?  That would be non-complaint. Take another look at the ACDIS/AHIMA query practice brief quoted above. Aside from those instructions, organizations need to be cautious about payer reviews and audits. Once an auditor notices a pattern of behavior, you could risk further investigations and possible penalties. It’s easier and much less costly to develop a departmental policy that addresses the issues that you’ve described.

Editor’s Note: Dawn Valdez, RN, LNC, CDIP, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at dvaldez@hcpro.com. For information regarding CDI Boot Camps, click here.