Q&A: How to determine an appropriate physician query response

Q: I enjoyed listening to the ACDIS quarterly conference call in May. Someone on the call stated they have a physician response rate of 95%. That caused me to wonder what the typical time frame for physician response might be; ours is 48 hours after discharge. I have heard some facilities give two weeks and some give up to 30 days, so I am wondering if there is some standard we should adopt.

A: Different facilities structure their programs differently. Many have no policy in place regarding expectations related to the timing of the physician’s response. That said, the most successful programs do set expectations typically of about 72 hours, and indicate on the query form itself that a response is expected within that time frame.

The goal is to have a high query response rate within that 72 hour time frame.  In other words, there is a difference between an organization with a 95% response rate where the queries are closed within 72 hours and one that has a 95% response rate, but the queries are left open indefinitely.  Best practice is to resolve any open query before billing.

Few organizations will hold a claim for 30 days pending a query response, since this can result in a re-billing situation if the query response changes the DRG assignment. An effective CDI department can positively impact bill hold times as it works to resolve open queries so the record is complete for coding within days of discharge.  Most organizations have a bill hold goal of three to five days.  Be sure to address in your CDI program’s policies and procedures how long a query can remain “open” or awaiting a response.

One of the most important aspects of tracking physician responses is to determine which physicians need extra support and education regarding the importance of CDI. An internal escalation process (such as the samples recently published in the CDI Journal) may be another way to address habitual non-responders.  Be sure to get hospital and physician leadership support for your deadlines and share them with the medical staff.

Also, you need to know if your organization voids those queries that no longer impact the DRG. For example, if a CDI specialist leaves a query for a CC but a different CC was coded, that query would be “voided” in some organizations. Then, when calculating your response rates you’d also have to void or remove those queries from the calculation; rather than a non-response counting against the query rate, that particular query would be removed from the equation.  Additionally, some organizations “close” a CDI query and “open” a coder query when a patient is discharged if their coding department then follows up on the query. Doing so can impact response rates as well as lower the CDI response rate.

As you can see, there are a lot of factors to consider when calculating a query response rate. It is difficult to compare organizations without knowing how long queries can remain “open” awaiting a response and what query resolution processes are in place.  Remember the value of the CDI department is in issuing queries to clarify incomplete, vague or missing documentation so query resolution should be a prominent task within the CDI role.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., answered this question which was originally published on the ACDIS Blog. Contact her at cericson@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview.