Note from the Associate Editorial Director: Leading the question

by Melissa Varnavas

Clinical documentation improvement specialists continue to have trouble discerning between leading and non-leading physician queries. The question often comes down to an understanding of the various previous “lives” of professionals. Nurses are used parrying over clinical decision making, so why should their queries regarding documentation be any different from the clinical questions they’re used to asking?  Quite simply: because there’s money involved.

Sure it’s true just as Robert S. Gold, MD, founder of  DCBA, Inc., in Atlanta, said in his article “Is asking for clarification ‘leading’?” that the government never clearly defined the term “leading”  and many experts continue to banter over the logistics of the language. However, CDI specialists need to shine a bright light on the differences between the leading and non-leading query to protect themselves and their facilities from the coming onslaught of government auditing agencies.

While the likelihood of true healthcare reform legislation seems to be dwindling, President Barack Obama nevertheless continues to push against apparent payment abuses throughout the system. CDI professionals are meant to be a facility’s first line of defense against such abuses. It a CDI specialist’s  job to make sure what was documented in the patient’s medical record is the most accurate description of the care the patient received.

Yet we still hear of facilities focused on Medicare only patients. We still hear about CDI programs directed to only look at records of a certain dollar value. We still hear tales of CDI professionals requesting specific language from physician simply due to some administratively imposed financial quota.

Inappropriate, leading queries, not only open your facility to an inordinate amount of risk but also jeopardize patient care. Generate policies and procedures for your facility that outlines the purpose and intent of your CDI program. Include your administrators, HIM leaders, physician liaisons, and compliance officers in the process. Create standard query forms that allow for the physician to further explain his or her documentation and even to disagree with the reason for the query.

For more information about physician query best practices and the legal architecture on which current query practice is based, read the Physicians Queries Handbook.

Editor's note: Varnavas is the associate editorial director of ACDIS. Contact her at mvarnavas@acdis.org.