Inpatient Facility Coding & Compliance Alert

Question: Sometimes we coders need to ask a physician to clarify things in a patient’s chart before we can code. Our supervisor is always warning us to not give the physicians "leading" queries. Can you explain that to us?

West Virginia Subscriber

Answer: Protocol in most hospitals advises coders (or others in the billing department) to initiate queries when a patient’s record is illegible, unclear, inconsistent, incomplete, or imprecise. AHIMA also recommends that queries to physicians be detailed, refer to clinical indicators that are already part of the patient’s record, and request that the provider use those indicators when giving an interpretation of the data. Queries can be initiated while the physician is still treating the patient in-house, in the time between the patient’s discharge and when the bill is sent, or after the bill has been submitted.

Coders might suspect a diagnosis based on the clinical indicators, but be wary of mentioning that in your query. That’s what your supervisor means by a "leading" query – one that might be worded in such a way as to lead the provider to a specific conclusion.

Why it matters: Queries that could be interpreted as leading the physician to document a certain response could lead to allegations of inappropriate upcoding, or fraud. In addition, all of the patient’s healthcare information gets entered into databases so future providers understand the patient’s medical history. Upcoding as a result of a leading query could lead to inappropriate care or incorrect diagnoses in the future.

Another possibility: Even if a facility isn’t accused of fraud, CMS will take back part – or all – of the money that was overpaid. The facility loses reimbursement, plus could become a target of sorts for other healthcare patrols. A charge of leading queries from a Medicare Recovery Audit Contractor (RAC) goes beyond a single case and opens the door to deeper investigations.

Work-around: Be specific enough in your query to help the provider understand the situation, but don’t be too detailed. Your note to the physician should focus on more general terms and the question should be phrased to have an open-ended or multiple choice answer. Writing individual queries also helps physicians have original answers. For example, physicians can become accustomed to specific queries (such as acute respiratory distress) and start adding diagnoses that could lead to higher DRG assignment. That situation could lead to fraud implications of their own.