Q&A: Questions from Brian’s Mailbox

Brian Murphy (our beloved ACDIS Director) routinely gets loads of e-mail and as much as he would love to be able to answer each message or question personally, the sheer volume can be overwhelming. So…he’s tossed a few questions my way and asked if I could address them.

The following are a few questions from his inbox:

Q: Should we document verbal queries in the record? Should we include paper queries in the record?

A: This is a matter for your facility to decide with collaboration from the CDS, HIM, and compliance departments. Let’s see what AHIMA had to say about this issue in the recently revised query brief Managing an Effective Query Process:

“Permanence and retention of the completed query form should be addressed in the healthcare entity’s policy, taking into account applicable state and quality improvement organization guidelines. The policy should specify whether the completed query will be a permanent part of the patient’s health record. If it will not be considered a permanent part of the patient’s health record (e.g., it might be considered a separate business record for the purpose of auditing, monitoring, and compliance), it is not subject to health record retention guidelines.”

So, there’s no hard and fast rule about this. Our facility does both. First, I’ll address the second part of the above question.

We have certain queries that have been approved as a permanent part of the medical record:

1. a CHF query form
2. a POA query form

These query forms went through several layers of review prior to final approval. They were developed in conjunction with our HIM director and compliance officer and reviewed by the forms committee prior to implementation. We really love them because they allow the physician to document their answer on the form, sign and date it, and we’re done.

All other paper queries are NOT a permanent part of the record, for good reason.

One: you can’t put every situation into a standardized query that has had the benefit of undergoing the above-mentioned review process. The whole question of whether a query is “leading” is still subject to individual interpretation. While each CDS on our team has read the revised query brief and knows the guidelines, their well-thought out and well-written query may still be considered “leading” by another set of eyes. That’s the problem we all face.

So, for anything but a CHF or POA query, those queries are removed from the health record when it goes through analysis and assembly. They are, however, retained by the CDS team for auditing and reporting.

Let me address the issue of documenting verbal queries in the record. Our facility uses an electronic worksheet software program that tracks verbal queries so we’re able to print a copy of the worksheet and include it in the record so that the coder is aware that a query was posed to clarify a particular condition.

Do I write down the details of my conversation with the physician? No, I just note something along the following lines: “verbal query to MD to ascertain the stage of CKD” or “verbal query to MD to clarify PDX”.

I wish all my queries could be verbal queries. A face-to-face conversation allows me to tailor my question to the particular physician. After being in this role for almost seven years I consider some physicians close friends and colleagues. Our dialogue is more informal and my question is often more directive.

This type of physician might say “Okay, I know you need something more here. What do you need me to write”? And I tell him (or her). Case closed.

With “resistant” physicians I may need to recap the goals of the program, outline the situation identified and answer several questions before they provide the requested clarification. It would certainly be difficult to capture this exchange in a written format.

Verbal queries were also addressed in the practice brief:

“Verbal queries have become more common as a component of the concurrent query rocess. The desired result of a verbal query is documentation by the provider that supports the coding of a condition, diagnosis, or procedure. Therefore entities should develop specific policies to clearly address this practice avoid avoid potential compliance risks.”

We must all remember that the goal of a query is to provide clarification of a situation so that the most appropriate diagnostic or procedural code can be assigned. There are times when this may positively affect reimbursement but this should NEVER be the primary goal.

You want your records to show a pattern of consistent documentation. When a diagnosis suddenly appears in the middle of a record and is never seen again, auditors will view this situation as a compliance risk and coders will be hesitant to code such a condition.

Now for question two: Can we only use multiple choice lists for queries?

The short answer is “no”. There are several instances where a multiple choice format is desirable.

An example might be where more than diagnosis could be correct: documenting the cause of a symptom (dyspnea or abdominal pain). In this case, to be perfectly compliant you need to include a list of clinically reasonable choices and include the choices of “unable to determine” and “other”.

There are times when there is only one appropriate answer (patient emergently intubated and placed on mechanical ventilation). What other diagnosis could there be except “acute (or acute on chronic) respiratory failure?” There would be no point in offering choices of “hypoxia” or “acute respiratory insufficiency.”

Experience has taught me that a successful CDI program makes use of both verbal and written queries and that the format used depends upon the particular situation. Whether your queries are written (either on paper or as part of the EMR) or verbal you need to keep the following in mind.

Healthcare entities can create and maintain a compliant query process by:

• Creating comprehensive policies and procedures for query processes
• Generating queries only when documentation is conflicting, incomplete or ambiguous
• Conducting auditing and monitoring activities to determine the effectiveness of the query process
• Providing eduation and training for the staff involved in conducting provider queries

Source: AHIMA, “Managing an Effective Query Process” Journal of AHIMA 79, no.10 (October 2008): 83-88

Editor's note: Lunne Spryszak, RN, CCDS, CPC, answered this question. Spryszak, at the time of this article's release, was an independent HIM consultant based in Roselle, IL. Her areas of expertise include clinical documentation and coding compliance, quality improvement, physician education, leadership and program development.