Q&A: Re-billing an account after a late query response

Q: AHIMA’s 2008 practice brief, “Managing an Effective Query Process,” appears to allow the initiation of post-bill queries as a result of an audit or other internal monitor. Historically we believed that a query completed after the initial bill was not permitted to be submitted for rebill (unless the documentation was present and the coder missed it) because the documentation was not present at the time of the original coding and bill submission. We have had a few cases in which our CDI nurse has initiated a concurrent query that was continued retrospectively; however the coder released the bill prematurely in error. If the physician answers the query after the bill has dropped would it be appropriate to rebill the account?

We have also had coding audits with recommendation that a query should have been initiated. Would it also be appropriate to initiate a post bill query in this situation? Again, we have not been rebilling up to this point but if it is permissible then we would develop a policy which would include billing parameters. We want to ensure that we are interpreting the guidance in the practice brief correctly.

A: “Managing an Effective Query Process,” p. 4, discusses initiating post-bill queries as a result of an audit or other internal monitor. The guidance states:

Healthcare entities may design their query programs to be concurrent, retrospective, post-bill, or a combination of any of these. Concurrent queries are initiated while the patient is still present. Retrospective queries are initiated after discharge and before the bill is submitted; post-bill queries are initiated after the bill has been submitted.

Concurrent queries are initiated “real time,” during the course of the patient encounter or hospitalization, at the time the documentation is naturally done. They thus encourage more timely, accurate, and reliable responses. Retrospective queries are effective in cases where additional information is available in the health record, in short stays where concurrent review was not completed, or whenever a concurrent query process is not feasible.

Post-bill queries are initiated after the claim is submitted or remittance advice is paid. Post-bill queries generally occur as a result of an audit or other internal monitor. Healthcare entities can develop a policy regarding whether they will generate post-bill queries and the timeframe following claims generation that queries may be initiated. They may consider the following three concepts in the development of a post-bill (including query) policy:

• Applying normal course of business guidelines
• Using payer-specific rules on rebilling timeframes
• Determining reliability of query response over time

A post bill query is always appropriate when, after an audit, an error was found. The goal of a CDI program is complete and accurate documentation regardless of the financial impact. All overpayments should always be re-billed regardless of the length of time since initially billed.  According to MLN Matters article SE 1027:

Lastly, CMS reminds providers to ensure that any information that affects the billed services and is acquired after physician documentation is complete must be added to the existing documentation in accordance with accepted standards for amending medical record documentation.

However, if a facility has a strong query follow-up process that includes timely closure of queries prior to final billing, the situation described above should occur infrequently. Some facilities who perform many post bill queries and changes have found themselves under scrutiny by Medicare Administrative Contractors and Recovery Audit Contractors. We have heard reports of hospitals that feel “targeted” if they do many post bill changes, and at other times they are targeted to see if there are quality-of-care issues. CDI programs should seek to prevent post bill queries through process changes that move query resolution pre-bill.

However, note that rebilling is permissible when queries are answered after the initial bill.  For example, facilities often drop a bill without a discharge summary, yet once the summary is completed (within the 30 day timeframe allowed by the CMS Conditions of Participation), it may conflict with what is written in the record or with the codes that were submitted.  A query would be necessary to resolve these prior to rebilling the account within the 60 days allotted.

If your CDI nurse initiates a concurrent query that was continued retrospectively and a member of your coding staff prematurely releases the bill, the record is not complete because the query was not answered.  If the physician answers the query after the bill has dropped you may rebill the account.

Regarding coding audits that recommend that a query should have been initiated and the appropriateness of initiating a post bill query in this situation: This is controversial and depends on whether the record is complete or not.

In general, we recommend the following as best practice:

• Develop an internal policy with the guidance of legal counsel
• Postbill query only when there is an obvious error or when you have a strong case
• Consider using a multi-disciplinary team to evaluate any re-bill accounts
• Develop a timeframe for query responses
• Monitor physicians’ query responses and develop response mechanisms for non- or chronically late responders
• Use external audit findings as educational opportunities to avoid the same issue in the future.

Editor’s Note: This question was answered by the ACDIS advisory board and published in the March 3 edition of CDI Strategies, the free bi-monthly e-newsletter published by ACDIS. Advice given is general in nature. Please seek legal counsel for definitive guidance. AHIMA’s 2008 practice brief, “Managing an Effective Query Process,” may be viewed at http://tinyurl.com/AHIMA2008QueryPracticeBrief.