Neurosurgery Coding Alert

During their Virtual HEALTHCON 2020 presentation, “Compliant Provider Queries,” speakers Wanda Register, MBA, CPC, CCS-P and Lee Williams, MBA, RHIA, CCS, CCDS, CPC, CPCO, CEMC, CHONC, CRC, discussed how to best handle queries in your practice including the goal of provider queries and reasons why you would need to submit a query.

Read on to learn more.

Grasp Focus of CDI Programs, Goal of Queries

“A query is a communication and educational tool that is utilized between the clinical documentation improvement (CDI) specialist and the provider to offer clarification about information documented in the medical record,” Williams said.

Although many facilities may prefer nurses as CDI specialists because of their clinical training, coders are also well positioned to work in this capacity, as well, according to Williams. Some tips she gives for coders to be successful in the role of a CDI specialist include learning medical terminology and pharmacology to better understand how the body works.

Why query? A query should never be used to question a provider’s clinical judgement, Williams emphasized.

Instead, “the goal of the query is to clarify information in the medical record, improving or increasing data integrity,” Williams said. “It should never be about maximizing revenue. If you do all things appropriately or correctly, that revenue maximization will come without you having to risk any compliance issues within your facility.”

“The real focus of any good CDI program is to enhance the quality of care for the patient,” Williams added.

Check Out 5 Reasons Why You May Need to Query

You may need to query your provider for the following various reasons, according to Williams:

• Legibility: This is defined as handwriting that cannot be read by two other individuals. If the CDI specialist or coder cannot read and input the information, they may need to query.
• Completeness: At times, there may be clinical indicators such as diagnostic labs, imaging, pathology, or prescribed medications found within the patient’s medical record. “If there is indication for a condition that is not documented by the provider, this may be another reason for issuing a query,” Williams said.
• Clarity: Oftentimes, signs and symptoms may be reported or present in the medical record, but your provider hasn’t established a definitive condition, which could be a reason to query.
• Consistency: Consistency involves variances within the medical record. “How many times have we seen documentation along the lines of ‘Mrs. Smith presents for follow-up of so and so condition,’ but later on in the encounter, ‘Mrs. Smith’ becomes ‘Mr. Smith’?” Williams asked.
• Precision: Although ICD-10-CM gave us an opportunity for increased specificity in code assignment, to assign codes to the highest level of specificity, we must have matching and supporting documentation.

Understand Different Types of Queries

Two types of queries are written and verbal, Register said.

Written queries: Your written paper and electronic queries should be composed in a clear and brief manner that identifies the suitable diagnoses and/or procedures that are key for the provider to accurately respond, according to Register. The three different types of written queries include open-ended, multiple choice, and yes/no.

Clinical indicators are an important factor regarding queries. For example, what information did the lab reports state? Register asked. What did the EKG state?

Remember: Your queries should always be legible and free of errors, Register added.

Verbal queries: When you use a verbal query, it should follow the same compliance standards as a written query, according to Register.

“I can remember when I worked in a physician’s office and we did verbal queries,” Register said. “The one thing I made sure I did right after I talked to the physician was write the information down because if you don’t, you might forget what was discussed when you were doing a verbal query.”

When you capture the documentation of a verbal discussion, make sure you include the clinical indicators, date, time, and signature of the query, treatments, and any possible diagnosis.

Query forms: Always make sure your query forms include the following information, according to Williams: the patient’s name, date of service, medical record number, provider’s name, name and contact of the individual sending the query, the query date, and statement of the issue in the form of a question as to what it is that you are querying.

Editor’s note: Want more great info like this? Early bird registration is now open for 2021 HEALTHCON in Dallas, Texas in March 28-31: http://www.healthcon.com/.

Follow These 6 Tips for Successful Queries

To be successful with queries, you can follow these tips from Register:

1. Implement a practical escalation policy: Make sure to have a chain of command. You should start with the coder or member of the CDI staff and know who is the next name to contact if a provider is not getting back to you in a timely manner about a query.
2. Identify frequent and risk targets: You should know who is getting the major denials in your practice. Is it a particular healthcare provider? Is it a particular diagnosis? Look at those patterns of denials
3. Advance pre-bill efforts to identify and correct problems: “Before that bill goes out the door, look at the coding, look at the documentation, and make sure everything is correct,” Register said.
4. Establish a well-detailed query process: Look at all your query process policies and procedures. Make sure you include examples of best practices to querying healthcare providers.
5. Seek feedback from providers, CDI, and coders: “These are the frontline people who are dealing with these queries,” Register said. “What do they think is the best way to query?”
6. Offer continuing education for providers, coders, and CDI staff: Educating providers, coders and CDI staff will give you the best query policies.

Editor’s note: Want more great info like this? Early bird registration is now open for 2021 HEALTHCON in Dallas, Texas in March 28-31: http://www.healthcon.com/.