Q&A: Ethical prospective querying

Q: A few facilities in our system have a schedule for certain units, such as the trauma unit. The physicians listed are the ones scheduled to cover those units. We are being instructed to go ahead and query those physicians if we see an opportunity even if the provider has not documented on the record at the time the query is issued. I just don’t feel comfortable with this practice but if I had a different perspective, I might be more open to the process. Is it okay to query a provider prior to them documenting in the record?

A: This is a great question, and one that shows you are thinking. In the outpatient setting, CDI professionals do ask questions prospectively (prior to the patient encounter). Because of the shortened time of an encounter, a concurrent review is not very practical. They base the need for query off previous documentation, the problem list, and any diagnostic data available. This is a common accepted practice, knowing a query should not be asked unless it is relevant to the planned encounter.

Your question, however, reflects practices within the inpatient setting. I would be hesitant to query a provider who has not yet documented within the record. I see a few issues related to such a practice, the two biggest being compliance and provider engagement. I would not want a physician to be hit with a question when they have not yet seen the patient or have not yet documented their assessment. I would think this would be frustrating for the physician and may be received negatively. When considering compliance in query practice, one should not lead a provider to a specific diagnosis. Although the reviewer may see clinical indicators to support a query, they should allow the provider the chance to document the desired condition before a query is placed.

Lastly, how do you compute CDI impact? For example, if I query before the provider has even documented their assessment and I ask for a diagnosis, and then the provider documents the diagnosis, who is to say the provider would not have documented it without a query? I think such a practice would inflate CDI impact dishonestly.

When I was reviewing records regularly, I often did review records before the history and physical or consult note was documented. I often would identify potential need for further specificity or for a diagnosis. But I kept that information in my CDI notes and would follow up once the documentation was present, to identify if the need for querying remained. I would not suggest asking a question beforehand.

I hope you find this information helpful. 

Editor’s Note: Laurie Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC, ACDIS interim director and CDI education director, answered this question. Contact her at lprescott@acdis.org.