TOP 20 Best Practice Physician Queries Questions Answered ICD 10 Coding Readiness Top 20 Questions Answered Education Series (Session 3 of 3)

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1 TOP 20 uestions nswered ICD 10 Coding Readiness Top 20 uestions nswered Education Series (Session 3 of 3) Presented July 7, 2015 by Ed O Beirne, MHS, CCS, Senior Managing Consultant and Tina Fletcher, RHIT, Senior Managing Consultant 1 Best Practice What constitutes best practice? Best practices can be defined as the most efficient and effective way of accomplishing a task, based on repeatable procedures that have proven themselves over time for large numbers of people. 2 1

2 IMPORTNT Communication tools between coding personnel and physicians such as coding summary sheets or physician queries should never be used as a substitute for appropriate physician documentation in the health record. 3 CMS Expectations 2 Rules to Live By CMS has two rules for physician queries: 1. The query cannot be leading. 2. The query cannot introduce new information that is not already present in the record. 4 2

3 No. 1 When is it appropriate to use a Physician uery? ueries may be used in situations such as the following: Health record documentation is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent Clinical indicators of a diagnosis are present but no documentation of the condition Clinical evidence of a higher degree of specificity or severity is needed cause and effect relationship between two conditions Is unclear for present on admission indicator assignment 5 No. 2 What is the provider s responsibility in documentation? ccording to CMS: Providers are expected to provide legible, complete, clear, consistent, precise, and reliable documentation of the patient s health history of present illness and course of treatment. a b c d 6 3

4 No. 3 Do we need a policy for physician queries? Individuals performing the query function should following their facility s internal policies related to documentation, querying, coding and compliance. 7 No. 4 How do I know which physician caring for the patient should receive the query? It depends: The query should be directed to the provider who originated the progress note or other report in question. query for abnormal test results should be directed to the attending physician Documentation that conflicts with that of another provider the attending physician is usually queried for clarification, as that provider is usually responsible for the diagnoses. 8 4

5 No. 5 When should a physician query not be done? ueries should not be done to question a provider s clinical judgment. In situations where the provider s documentation or diagnosis does not appear to be supported by clinical findings a facility s policies can provide advice on a process for addressing the issue without querying the attending physician. 9 No. 6 Do industry experts provide any criteria for when physician queries are necessary? ueries may be considered when documentation in the patient s record fails to meet one of the following five criteria: 1. Legibility 2. Completeness 3. Clarity 4. Consistency 5. Precision 10 5

6 No. 7 Is it appropriate to query for present on admission indicators following patient discharge? Yes! H Coding Clinic Third uarter 2008 instructs coders that there is no required timeframe as to when a provider must identify or document a condition to be present on admission. It is appropriate to query the physician for clarification even following discharge. 11 No. 8 What should be included in a physician query? Your facility policy should address the query format. ueries generally include: 1. Patient name 2. dmission date and/or date of service 3. Health record number 4. ccount number 5. Date query initiated 6. Name and contact information of the individual initiating the query 7. Statement of the issue in the form of a question along with clinical indicators specified from the patient s individual record BEST PRCTICE Use Facility pproved uery Forms 12 6

7 No. 9 What is meant by the term leading query? ueries that appear to lead the provider to a particular response could result in allegations of inappropriate up coding. The query format should not sound presumptive, directing, prodding, probing or as though the provider is being led to make an assumption. 13 No. 9 uery Example Clinical scenario Obtunded male patient admitted with three day history of nausea and vomiting. CXR revealed right lower lobe pneumonia. Clindamycin ordered. Leading query Is the patient s pneumonia due to aspiration? Non leading query Can the etiology of the patient s pneumonia be further specified? It is noted in the admitting history and physical exam this obtunded patient had a history of nausea and vomiting and is treated with clindamycin for RLL pneumonia. Based on the above can the etiology of the pneumonia be further specified? If so, please document the type/etiology of the pneumonia in the progress notes. 14 7

8 No. 10 What about information that is not in the record? The introduction of new information not previously documented in the medical record is inappropriate in a query. Example Dr. Harris: ccording to the patient s emergency room record from last week, the patient was placed on antibiotics for cellulitis of her leg. If the patient is still taking antibiotics, please document the cellulitis. 15 No. 11 re Yes/No physician queries okay? Open ended queries are preferred. Yes/No queries are acceptable under certain circumstances. This That This Other Thing Let s take a look at a couple of examples. 16 8

9 No. 11 Yes/No uery Example Clinical scenario In the impression of the pathology report ovarian cancer is documented; however, only ovarian mass is documented in the final discharge statement by the provider. Do you agree with the pathology report specifying the ovarian mass as an ovarian cancer? Please document your response in the health record or below. Yes No Other Clinically undetermined Name: Date: 17 No. 11 Yes/No uery Example Clinical scenario Consulting pulmonologist documents pneumonia as an impression based on the chest x ray. However, the attending physician documents bronchitis throughout the record, including in the discharge summary. Do you agree with the pulmonologist s impression that the patient has pneumonia? Please document your response in the health record or below. Yes No Other Clinically undetermined Name: Date: 18 9

10 No. 12 Is it acceptable to include DRG weights or reimbursement information on a physician query? The query should never indicate that a particular response would favorably or unfavorably affect reimbursement or quality reporting. 19 No. 13 What elements should be reviewed before a query goes out to the physician? Concurrent or retrospective review of queries can ensure that they are done to according to documented policies. Review: 1. That the query was needed 2. Language in the query was not leading 3. The query did not introduce new information into the health record 20 10

11 No. 14 If we are doing retrospective review of our physician queries and find a leading query what should we do? For retrospective physician query review be sure to identify follow up actions. Example What action should be taken if a leading query is found that led to inaccurate code assignment that will require that codes be corrected to the level supported by the documentation without the leading query? Follow facility policy. 21 No. 15 What metrics can we use to measure our success in using physician queries in our CDI program? Create a Physician Report Card verage length of time to answer a query Number of queries not responded to udit high risk or problem diagnoses udit individual providers Include a representative sample of total queries, including all providers and all individuals initiating queries 22 11

12 No. 16 Should queries be a part of the permanent record? From a compliance perspective, the risk is not whether or not to include queries as part of the medical record, but whether or not we are correctly conducting queries to clarify the intent of the physician. Best Practice is to have the information documented in the patient s medical record. uery Retention If the documentation is only on the query form then the query should become part of the permanent record. If you opt not to maintain query forms in the health record then they should be maintained as copies of the administrative business record. 23 No. 17 Is the physician query a legal part of the medical record that must be provided pursuant to a RC request? We know that RC auditors have been requesting physician queries during audits. The RCs are reviewing whether the documents provided support the principal and secondary diagnoses assigned by the hospital coder. From experience we have learned it may be in the facility s best interest to provide the query. gain, follow your facility policy

13 No Due to the volume of information we want to provide you in response to the next question it will be the final one. Up Next.. Special Focus on ICD 10 Readiness 25 Last One What can we do now to be prepared for the changes the ICD 10 implementation will bring? Become familiar with ICD 10 CM/PCS code structure now Review the Official Coding Guidelines for both CM/PCS Re audit documentation, query forms, make revisions and improvements Increase your clinical knowledge Hands on practice 26 13

14 ICD 10 ueries Use available resources. When revising query templates, refer to the ICD 10 CM/PCS manuals as well as HIM s query practice brief, Guidelines for chieving a Compliance uery Practice. s Coding Clinic begins to publish ICD 10 related questions and answers, be sure to review this information as well. See more at: queriesto prepare for icd 10 cmpcs/#sthash.d5qlgdlv.dpuf 27 Team Up It may be challenging for coders to translate some of the clinical details of ICD 10 CM/PCS into query templates without leading physicians. CDI staff need to understand the full extent of the new Official Guidelines for Coding and Reporting. Coders and CDI staff should work together with their physician champion when revising templates 28 14

15 Take It Slow Dual Coding is key. s coders currently assign codes, they can be on the lookout for problem areas. The challenge is that if they are not very familiar with ICD 10 CM/PCS, they don t know what those problem areas are yet. It will come with time. 29 Plan head Finding the time and resources to devote to this effort may be challenging. We don t want to have massive volumes of queries being generated and sent to physicians on October 1. You want to be proactive rather than reactive, so use the coming months to get ready

16 nticipate uery Increases for Both ICD 10 CM and PCS dditional queries guaranteed Not just diagnoses but procedure queries Think laterality Muscle/vessel specificity Think joints and fractures 31 nticipate ueries for ICD 10 PCS Root Operation Body Part Body System 32 16

17 ICD 10 PCS Does Not Include Unspecified Clinicians will see an increased number of queries on procedures post implementation. CDI professionals, inpatient coders, and clinicians should focus on several important documentation areas during the next year to prepare for ICD 10 PCS implementation. 33 Root Operations Coders must understand that physicians are not obligated to use root operation terminology in their documentation

18 Have a uery Plan October 1 Educate first Do not flood providers with dozens of queries Decide what you will query on first and build Focus on most common and high risk PCS will necessitate queries 35 Thank you HIM Consulting Coder Education Physician Education CDI Dual Coding udits Validation udits RC Support Remote Coding Professional Fee Facility Multiple Specialties Guaranteed uality 100% US Based Patient Financial Services CBO Rehab and Return Self Pay R Projects thebench@hrgpros.com 36 18

19 References Prophet, Sue. Developing an Effective Physician uery Process. Journal of HIM 72, no. 9 (Oct. 2001) cumentra Health Sturgeon, Judy. The uery uagmire. merican Health Information Management ssociation, Managing an Effective uery Process, Journal of HIM 79. no. 10, (2008) ssociation of Clinical Documentation Improvement Specialists, &, CDIS dvisory Board weighs in on Physician uery Form Retention, CDI Strategies, (July 9, 2009) CMS RC conference call (pril 29, 2010) H Coding Clinic 37 19