Q&A: Pre-bill query process requires a defined policy and procedure

Q: What does ‘pre-bill retrospective physician query process’ mean?

A:A pre-bill retrospective query process is when the patient is already discharged and the physician is queried (or an unanswered query is closed out) before final coding and billing takes place. In many facilities the query is “owned” by the CDI specialist until an answer is obtained. In other facilities unanswered queries or query opportunities identified after discharge become the responsibility of the coder.

In either situation facilities should design a process for getting the required documentation before final coding and billing takes place. Think of it as “getting it right the first time.” You don’t want to have to re-code and re-bill the case if you obtain additional information after the bill goes out since doing so often raises a red flag from an auditing perspective.

For example, if a coder sees an outstanding query remaining in the record then he or she should flag the case as containing a deficiency and delay final billing until an answer is obtained from the provider. Of course you don’t want to hold these cases forever since it impacts the revenue cycle. That’s another reason for the facility (HIM and CDI department management jointly) to create a series of policies and procedures that:

• Outline exactly how long to hold the case before final coding and billing
• Define who is responsible for query follow- up
• Describe exactly what to do (and what the next step is) if the provider doesn’t respond

Editor’s Note: Lynne Spryszak, RN, CPC-A, CCDS, CDI education director for HCPro, Inc., in Danvers, MA, answered this question. Contact her at lspryszak@hcpro.com.