Anesthesia Coding Alert

Whether written or verbal, get the clearest documentation possible.

There is never a bad time to brush up on communication skills, and how you handle queries to your physicians can be an important part of your repertoire. Queries also are an important aspect of any clinical documentation improvement (CDI) program and can make a difference in ensuring that claims are clear and concise.

Maximize your knowledge and efficiency with these expert tips for writing queries and analyzing physicians’ answers from Leonta Williams, RHIT, CPCO, CPC, CEMC, CHONC, CCD, CCDS, who presented at this year’s virtual 2020 HEALTHCON.

When your Revenue Cycle Management (RCM) department knows how to write effective queries, you can help clinicians improve their clinical documentation and improve your ICD-10-CM coding, Williams notes.

Find Out What Constitutes a Query

You write a query when something about the physician’s documentation is confusing, conflicting, or lacking in detail. Before you submit a query, make sure you’ve brushed up enough on your clinical skills to understand what you’re reading, Williams recommends. If you submit a query about clinical information you should know, “that lessens your credibility” in your practice.

Send a query when the documentation seems to be missing a key fact. For example, the note may contain signs and symptoms, but not a documented condition. (And, you’re pretty sure the provider isn’t waiting on lab or biopsy results.) Or, the note may contain what appears to be conflicting information. Or, perhaps you need additional information in order to assign the correct ICD-10-CM code. You might even be dealing with a paper record that contains illegible handwriting.

“A query is a routine communication and education tool used to advocate complete and compliant documentation,” according to the American Health Information Management Association (AHIMA)’s “2019 update: Guidelines for achieving a compliant query practice.”

“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.”

Review Medicare Guidance on Queries

Williams says your query forms should:

• Be clearly and concisely written
• Present the facts and identify why the clarification is needed
• Present the scenario

Query forms should not:

• Be designed so that the only thing needed is a physician’s signature
• Indicate any financial impact

Rumors abound that some physicians are asking coders to mention reimbursement dollar amounts in their queries. Make sure you steer away from that practice and follow the Centers for Medicare & Medicaid Services (CMS) guidelines to remain compliant. Never mention dollar amounts in your queries, Williams stresses.

Add These Elements to Written Queries

Written queries are best, but they can be verbal as long as you document the verbal exchange. Queries can even be conducted over email — as long as your practice’s email system is secure and HIPAA-compliant.

“I prefer to send email inquiries so the provider can reply at their own convenience,” says Natalie Ruggieri- Buzzelli, CPC, CGSC, HIM coding specialist at the Hospital of the University of Pennsylvania. “When doing so, be sure to keep the email short and to the point; providers don’t typically have a lot of time to read a lengthy email. Lastly, make sure that you proofread and conduct all relevant research prior to sending your inquiry. You not only want to gain the providers trust, but also their respect with well thought out and researched inquiries.”

The form should list the patient’s name, date of service, medical record number, provider’s name, name and contact of the individual sending the query, date of query, and the statement of the issue in the form of a question or request for additional information.

Word your query carefully so that you “don’t box the provider in,” Williams says. Steer clear of ‘leading’ queries that give providers only one way to answer the question. Williams offers the following example of a leading query: Was the patient given IV fluids because she was dehydrated? Instead ask, Why was the patient given IV fluids?

Queries should be “non-leading,” even if you think you know what the provider meant to document. You might ask for an addendum or provide multiple-choice options that include an “other” option to help the provider articulate their thinking in the medical note. Pay close attention to the headings you use for queries, Williams cautions, because sometimes headings can cause the query to be leading.

Track it: Because queries take up staff and provider time, they can cost a practice money if queries cover the same topics over and over again. Help alleviate some of the repetition – and gather valuable information to help educate providers and staff – by setting up a query tracking system.

Williams recommends setting up a form in Excel that records:

• Most common reasons for queries;
• Providers with a high query percentage;
• Providers with a low query rate;
• Query themes that reoccur repeatedly;
• Provider response turn-around time; and
• Provider agreement rate.

Caveat: “Be wary of the provider who agrees with the coder’s query 100 percent of the time,” Williams cautions.

Query tracking can help identify patterns and help improve documentation habits. As you build your CDI program, 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 resulting in better documentation, less back-and-forth time wasted, faster claims submissions, reduced denials and fewer appeals.