Query Physicians for Clinical Documenation Improvement
Does your physicians’ documentation sometimes need a quality check? Nobody’s perfect, and no matter how clinically skilled your providers are, there are times when you’ll need to clarify exactly what went on in those exam rooms. Physician queries—and the answers to them—are a crucial part of any clinical documentation improvement (CDI) program. especially as value-based reimbursement continues to ramp up. Here’s why:
Your coding does more than just get you paid for what your provider did (aka fee-for-service). Codes are data, and that data is used in ways that will directly affect your revenue like quality reporting (hello, MIPS), physician report cards (the Physician Compare website), and more. So high-quality coding is essential to your practice’s profitability. And the quality of your coding depends directly upon the quality of your physicians’ documentation.
If your coders know how to write good physician queries, you can help providers improve their clinical documentation and improve your ICD-10 coding, noted Leonta Williams, RHIT, CPCO, CPC, CEMC, CHONC, CCS, CCDS, who taught the p’s and q’s of queries at 2017’s American Academy of Professional Coders Regional Conference. But if you think any old questions will do, think again. Below, we show you how to write compliant queries that get you the answers you need.
You write a physician query when something about the physician’s documentation is confusing you. “It could be lots of different things,” says Jackie Stack, BSHA, CPC, CPMA, CPC-I, CPB, CEMC, CFPC, CIMC, COPC, CPEDC, a practice optimization and documentation expert at Eye Care Leaders. “But it’s basically something that’s going to prevent the claim from getting paid.” Queries can also help you catch errors before they turn into denials, reducing the time staff spends working on appeals. “You want to catch those things and query the provider so you can fix the problem and submit a clean claim to the payer,” Stack says.
“A query is a routine communication and education tool used to advocate complete and compliant documentation,” according to the American Health Information Management Association. “The desired outcome is an update of the health record to better reflect the provider’s intent and clinical thought process,” AHIMA adds. “A proper query ensures that appropriate documentation appears in the health record.”
Resource: To read AHIMA guidelines on queries, go here.
A written query is always best. You can even query via email as long as your practices email system is HIPAA-compliant. But queries can also be verbal. Just be sure to document that verbal exchange.
A query should contain at least these 7 essential elements:
- Patient name
- Date of service
- Medical record/account number
- Provider’s name
- name and contact of the individual sending the query
- Date of query
- Issue in the form of a question
To Query, or Not to Query?
Like its name suggests, a query is always presented to the provider as a question. It includes specific clinical information from a patients chart, and asks the physician to clarify that information in some way. A query never introduces new information or patient information from a prior visit.
Queries take up staff and provider time, costing your practice money. And some providers just don’t like to be “bothered” with queries. To show providers that you value their time, knowing when not to query is just as important as knowing when to do so.
- You’re confused because the documentation seems to be missing a key fact.
- The note contains what appears to be ambiguous or conflicting information.
- You need additional information (like laterality or a higher level of specificity) to assign the correct code.
- You’re using paper charts (like many ASCs do) and the physician’s handwriting is illegible.
Don’t query when:
- You’re confused because you don’t know something that you should. If you submit a query about clinical information you should know, “that lessens your credibility” in your practice, warns Williams.
- Your intent is to question the provider’s clinical judgment.
Tip: “Avoid the words ‘you’ and ‘but’ in your queries,” Williams advised. Such language can sometimes provoke a defensive reaction.
- The query involves clinically insignificant, extraneous, or irrelevant information. Only query about items that affect your ability to code the claim.
- The intent is strictly about reimbursement. Never mention dollar amounts in your physician queries, Williams stressed. Stack agrees. “We never want to say ‘if you change this code it will be covered,’ she says. “We are coding and billing and based on documentation and what happened with the patient, not billing or coding just to get paid.”
One of the trickiest parts of writing compliant physician queries is avoiding leading queries—you can’t “lead” the provider to a suggested answer. Leading queries hamper your CDI efforts and can cause all sorts of compliance headaches, warns Williams. Word your query carefully so that you “don’t box the provider in,” Williams instructed conference attendees. “Always leave your query open-ended, even if you think you know the answer.”
You can identify leading queries these red flags:
Red Flag #1:
Queries that give providers only one way to answer the question
Example: Note documents a vitreous tap OS with intravitreal injection of vancomycin and ceftazidime. The diagnoses states endophthalmitis OD. The patients chief complaint lists symptoms OS. Please change the laterality of the diagnosis to OS.
Red Flag #2:
Queries that only require only a yes/no answer
Example: Surgical note states cataract removal OS. Note indicates Trypan Blue was used to stain the anterior capsule. Would you agree that this procedure qualifies as complex?
Red Flag #3:
Statements that only require a physician’s signature to indicate agreement.
Example: Patient record refers to findings from a fluorescein angiogram, but there is no documentation that the test was performed. Please document if you agree that a fluorescien angiogram was performed on October 21st.
If your queries look anything like these, you’ll have to reword them. How?
For the most part, compliant queries cannot be answered with a simple yes or no, or just a signature showing agreement. You might ask for an addendum, or provide some multiple-choice options that include an “other” option to help the provider articulate their thinking in the medical note and document something other than what you suggested. You might also include “undetermined” among the choices if you think the physician could be waiting on the results of diagnostic tests.
And pay close attention to the headings you use for physician queries, Williams cautioned, because sometimes headings can cause the query to be leading.
Many providers dislike queries, so you and your revenue cycle team should communicate that the ultimate goal of your query program is to reduce the need for queries in the first place.
In order to make data-based decisions based on what is actually going on in your practice, Williams recommends that you set up a query tracking form in Excel—or another program that works for you—that records:
- Most common reasons for queries
- Providers with a high query percentage
- Providers with a low query rate
- Query themes that reoccur over and over again: Where might you focus your education efforts?
- Provider response turn-around time
- Provider agree rate—“Be wary of the provider who agrees with the coder’s query 100 percent of the time,” Williams cautioned.
The query tracking can help you discern patterns that help you build your CDI program. For example, you might enlist the physician who is queried least often to be your CDI champion. If you and the doctors work together, you’ll see a return on investment that includes better documentation, less back-and-forth time wasted, faster claims submissions, reduced denials, and fewer appeals.
“When your providers and staff are educated on things like annual code updates, covered and non-covered service, modifiers, and other relevant topics, you’ll end up with fewer queries,” Stack notes. For staff, Stack recommends group training sessions. “You want all of your employees to hear the same thing, at the same time, in the same way, so that you have consistency across the board,” she explains.
With physicians, it’s harder to get them all in a group. When problems arise, individual training on a case-by-case basis works best. “When you go to someone with an issue, and you’re saying to them ‘you can’t do this for that reason’ it’s always good to have the documentation to back you up,” Stack advises. For example, “if we know that a certain diagnosis is never covered with a certain procedure, I like to pull that documentation and be able to show them,” she says.
If your practice outsources coding and billing, be sure you agree on how often you’ll receive queries from your vendor. “If you get a spreadsheet monthly and its 300 lines, you’re going to close it and ignore it, and it will continue to grow,” says Stack. It could even start to erode your revenue if timely filing deadlines pass. But “if you get that report a couple of times a week or even weekly, you’ll take care of those much more quickly,” she explains. Stack recommends select a point person on your staff through whom all queries are filtered. That way, you can weed things out that don’t necessarily need to go to the provider.
The Best Defense
Clear and accurate documentation does more than transmit data and get you reimbursements. It can make or break you when it comes to malpractice claims. “Coders read so many notes that we sometimes think we know what the physician meant to say,” says Williams. But coding like that—which you definitely shouldn’t—creates another problem: essential documentation never makes it into the patient record. That can cost you big if a case is ever filed.
Patient records are the “most concrete visual evidence of the providers’ actions and decision-making process,” says David E. Silverstone, MD, who presented at AAO 2017. Experts review and comment on these charts during depositions and testimonies, and they are frequently admitted for a jury to use in deliberations.
“Lawsuits are filed long after the charting is done…and cases once filed can take years to resolve,” says. If the information is not in the chart, there’s a very slim chance you’ll remember exactly what happened on a random Wednesday morning two years ago—at least not in a way that will be convincing to attorneys or a jury. “EHR issues are becoming a significant source of litigation expense and discovery dispute,” Silverstone adds.
Poor charting can make good care look bad, says Cameron Cobden, JD, who spoke alongside Silverstone. When you have to talk about [the care] to someone else involved, it’s going to be very difficult to explain what happened if the record isn’t accurate or well-documented, she says. “You’re going to be in a situation where your chart loses its relevance,” she says. “It’s more than embarrassing, it’s dangerous.”
The lesson? Information gleaned from a query must become a documented part of the medical record. But remember—retroactively changing what’s in the patient record is a huge compliance no-no.“For anything documentation related, the physician has to go in and do an addendum,” explains Stack.
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