Q&A: Keeping electronic query copies

Q: Our program does not typically include query information as part of the medical record. If the physician responds to a faxed query, we scan the fax into our electronic record. However, we resolve most queries in person or through a secure messaging system in our EMR (we use EPIC). Once the physician updates the chart, or replies back explaining his/her disagreement to the query, the query is considered “done” and we close the chart. The secure messaging system could be audited, if need be, but is really considered outside the chart.  Should we be concerned about this or change our practices at this point due to additional auditor scrutiny?

A: If you’re using a messaging system for querying, I would just caution you to ensure that the provider is actually adding the necessary clarification to the progress notes or other part of the record.  Also, beware of responses on a fax or other query form if that is the only place the physician clarifies the documentation. The RACs seem to tend to deny those diagnoses since they appear only once or twice and are often omitted from the discharge summary. Many of the RACs are now denying diagnoses that are not included in the discharge summary. Sure, it is not fair, or even representative of the coding rules, but then who’s to stop them?

Editor’s Note: Lynne Spryszak, RN, CPC-A, answered this question. At the time of this article's original release, Spryszak was CDI Education Director for HCPro Inc., Danvers, MA.