Outpatient Facility Coding Alert

Remember: Query forms should never indicate any financial impact.

Physician queries, and the answers to them, are a crucial part of any clinical documentation improvement (CDI) program. But writing queries and analyzing query data as you grow your outpatient facility's CDI program requires smarts and skills.

In a class she taught at the American Academy of Professional Coders Regional Conference in Salt Lake City, Leonta Williams, RHIT, CPCO, CPC, CEMC, CHONC, CCS, CCDS, schooled attendees on the art and science of writing outpatient queries. There are clear guidelines for writing inpatient queries, and inpatient coders often have four or five days during a patient's hospital stay to query physicians for the documentation they need for correct ICD-10 coding, noted Williams, who is director of medical coding at Georgia Cancer Specialists.

Outpatient queries are trickier, Williams said. Patients are in your facility for only a day, and outpatient query guidelines from regulators and payers aren't as clear-cut. So outpatient queries can seem like "the Wild, Wild West," William said. Read on for Williams' answers to frequently-asked questions about outpatient queries.

What is a query?

Answer: You write a query when something about the physician's documentation is confusing to you. However, before you submit a query, make sure you've brushed up enough on your clinical skills to understand what you're reading, Williams stressed. If you submit a query about clinical information you should know, "that lessens your credibility in your facility."

You might write a query when the documentation seems to be missing a key fact. For example, the note might contain signs and symptoms, but not a documented condition. Or, the note may contain what appears to be conflicting information. Or, perhaps you need additional information to in order to assign the correct ICD-10 code. For example, if the provider documents simply "CHF" you need to know what kind of CHF in order to code to the highest level of specificity. 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). "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's guidelines on queries, go to: https://acdis.org/sites/acdis/files/resources/Guidelines for Achieving a Compliant Query Practice - 2016 Update.pdf.

Are there CMS guidelines for queries?

Answer: Yes, Williams said. 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.

Some physicians are asking coders to mention reimbursement dollar amounts in their queries, Williams noted. Make sure you steer away from that practice and follow CMS guidelines to remain compliant. Never mention dollar amounts in your queries.

Must the query be in writing?

Answer: Written queries are best, but they can be verbal as long as you document the verbal exchange.

Can a query happen over email?

Answer: Yes, as long as your facility's email system is secure and HIPAA-compliant.

What should a query form contain?

Answer: The form should list the patient's name, date of service, MRN#, provider's name, name and contact of the individual sending the query, date of the query, and the statement of the issue in the form of a question.

Word your query carefully so that you "don't box the provider in," Williams instructed conference attendees. Steer clear of "leading" queries that give providers only one way to answer the question. Williams provided the following examples of leading queries:

• Was the dysphasia caused by the previous TIA in the patient's PMH?
• Was the patient given IV fluids because she was dehydrated?

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 some 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 cautioned, because sometimes headings can cause the query to be leading.

Tip: "Avoid the words 'you' and 'but' in your queries," Williams advised. Such language can sometimes provoke a defensive reaction.

Keep reading: To get additional tips on query writing and to test your skills, go to: https://www.aapc.com/codes/coding-newsletters/my-outpatient-facility-coding-alert/cdi-test-yourself-can-you-spot-the-mistakes-that-lead-to-leading-queries-155894-article.

Queries take a lot of staff time and cost my facility money. How can we educate providers so that we don't have to query them as often?

Answer: Most providers dislike queries too, so you and the coding team should communicate to them that the ultimate goal of your query program is to reduce the need for queries in the first place. Williams recommends your facility's coding team set up a query tracking 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 over and over again: Where might you focus your physician education efforts?
• Provider response turn-around time
• Provider agreement 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, and reduced denials.

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