Tip: Adapt policies and procedures for physician queries

When AHIMA released its “Managing an Effective Query Process” brief in September 2008, it raised a number of concerns among them the responsibility of a CDI program to draft consistent policies and procedures for conducting physician queries. In a recent ACDIS poll, 29% of respondents said they did not have a query policy in place and 43% said their facility allows CDI staff a “flexible” query system.

Be careful about developing multiple rules for your facility query process, says Garri Garrison, RN, CPUR, CPC, CMC, director of consulting services for 3M Health Information Services in Atlanta.  The Department of Justice and the Office of the Inspector General “don’t care who asked the question”—either the HIM professionals in the coding department or a registered nurse in the CDI program—if the query leads the physician to document in an inappropriate way. So make sure when you develop your policy that you establish one approach and that everyone involved in the CDI program—coder, nurse, physician advisor—follows that approach.

Hear what Gloryanne Bryant, RHIA, CCS, senior director corporate coding HIM compliance department at Catholic Healthcare West in San Francisco had to say during the ACDIS quarterly conference call:

The quarterly conference calls allows ACDIS members to speak with each other and industry experts as an informal networking opportunity. Those who are unable to listen to the call “live” may access the MP3 recording of the call on the ACDIS Web site.

ACDIS has a number of sample policies and procedures available in the Forms & Tools section of the Web site. Download a sample inpatient physician query policy that you can adapt to your facility’s needs.