Note from the Instructor: Be wary of verbal query compliance
by Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC
I learned a lot from my father growing up. One of the main things he taught me was punctuality. His thought was you must arrive 15 minutes early to be considered on time. And, if you were going to be late, just don’t bother going at all. He felt punctuality was a matter of respect, and I agree. The second trait that I know came straight from him was we must follow the rules. I don’t think a week goes by that I don’t hear myself saying, “My dad taught me to be a rule follower.” He taught me that even if I disagreed with the rule, I needed to follow it. He also taught me not to follow it blindly, though; I could question the rule and work to make change if I disagreed.
Our work, as CDI specialists and coders, is one directed by the rules, the guidelines, compliance, etc. To perform our role successfully, to maintain the respect of our colleagues, to avoid putting our organization or ourselves at risk, we need to ensure our practice is compliant. As CDI specialists, our biggest compliance vulnerability is how we communicate with providers and ask provider queries. How many times have you been asked by a provider, “Just tell me what you want me to write,” and how many times have you instructed a provider to “just write x, y, z….” I think everyone needs to look at their habits and identify areas where they may need to improve.
While teaching class a few weeks ago, one of the attendees spoke up and stated she used verbal queries all the time with her providers because she could “direct” them towards the desired answer. My question to her was “how do you direct the provider to the right answer?” She smiled, knowing I was asking whether she led the provider and I expected an answer in response that stated she knew she couldn’t lead the provider. Her answer surprised me, she explained that as a nurse with years of clinical experience, she could make subtle suggestions or sometimes even blatant statements so that the provider could understand what they “should write.” She followed that statement by saying that verbally we had more freedom then we do with written queries.
Well, you know I could not let that statement go unchallenged. She (and all of us, for that matter) need to always understand that a verbal query means the same as a written query. Every discussion, every verbal exchange related to a specific record, must be recorded and stored per hospital policy. We need to summarize every verbal query in writing for compliance purposes. We need to demonstrate we followed the rules. Please understand, I love verbal queries and interaction with providers. I think we learn and the providers learn when we have these discussions. But when we verbally query, the same rules apply as if those queries were in writing.
We finished our discussion on query practice in class, and I noted to myself that I did want to speak to this individual one-on-one after class. I wanted her to understand the importance of compliance in these verbal exchanges. I didn’t want her to think what she described was okay. During a break, another attendee spoke with me wanting to share her experience related to verbal querying.
She worked for a large healthcare organization that was being investigated for a number of false claims act allegations. While the investigators were onsite, they observed interactions between CDI staff and providers and identified noncompliant, leading exchanges. This was not the focus of the original investigation, but as a result of these observations, the organization was fined an additional $46 million. The observations were labeled as “upcoding” by the investigators. As a result of this incident, the CDI department was immediately shut down and its staff required to complete additional training and increased focus on compliance, especially related to verbal queries.
I don’t share this story to scare you; I share it to alert you that we often don’t take the rules seriously. We drop our guard, lower our standards just a little bit at a time and with each little stray from the compliant approach, we don’t notice how far we’ve moved. When discussing compliant query practice, I suggest that organizations complete reviews of their policies annually, perform audit activities to ensure written queries are applied compliantly. Do you also review how verbal queries are handled? Are verbal queries recorded and tracked? Are verbal queries asked in an open ended format? How do you respond when the provider asks, “what do you want me to write?”
My standard answer to these question, because I am a rule follower is, “I want you to write what is right and true to this patient, this encounter.”
Editor’s note: Prescott is the CDI Education Director at HCPro in Middleton, Massachusetts. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps, visit www.hcprobootcamps.com/courses/10040/overview.