Title: Query Procedure for Wildcat facility
Course: HIM 3620 - TAACCCT Grant > Section: Module 6 - Queries

CDI QUERY POLICY

Purpose

To clarify physician documentation whenever there is conflicting, ambiguous, or incomplete information in the health record regarding any significant, reportable condition or procedure.

Scope

Wildcat facility will implement this policy in order to support the intentions of a query:

Identify clinical indicators  when no supporting diagnosis is documented

- Ensure accurate coding based on documentation specificity
- Shape the cause–and–effect relationships between two (2) or more conditions.
- Uncover the underlying diagnosis/etiology of symptoms
- Documentation of the diagnosis when the only the treatment is documented
- Clarification of a condition as a complication

Goal

The goal will be accomplished through:

- Improving the accuracy, integrity and quality of patient data
- Minimizing the variation in the query process
- Promoting the accurate code assignment and/or POA indication
- Reflecting the patient’s clinical condition for Severity of Illness (SOI) and Risk of Mortality (ROI)

Employee responsibilities

CDI employees will have strong competencies in the following areas:

- Knowledge of healthcare regulations, including reimbursement and documentation requirements
- Clinical knowledge with training in pathophysiology
- Analysis of information in  a patient’s health record
- Development of channels of communication with providers and other clinicians.

Definitions

CDS professional-Clinical Documentation Specialist - an individual who reviews health records on a concurrent basis and aids the provider if opportunities to improve documentation are identified.

Query – an established mechanism of communication between Clinical Documentation Specialist (CDS)/ Coders and providers to clarify ambiguous, incomplete, or conflicting documentation in the health record.

Concurrent Query – a query initiated before the patient has been discharged from the facility.

Retrospective Query – a query initiated after the patient has been discharged from the facility, but before the claim is final coded/billed.

Post Billing Query – a query executed within 12 months of the discharge date as a result of additional documentation (e.g., discharge summary).

Provider – a physician or qualified health care practitioner who is legally responsible for the patient’s diagnosis.

Procedure/Process Flow

- A query will include the following information:

1. Patient Name
2. Admission date and/or date of service
3. Medical record number
4. Account number
5. Date query initiated
6. Name and contact information of the CDS initiating the query
7. Statement of the issue in the form of a question along with clinical indicators
8. Physician name

- The CDI professional will follow the recommendations as provided in “Managing an Effective Query Process” published by the American Health Information Management Association (AHIMA).
- Queries, whether retrospective or concurrent, should be documented using black or blue ink or printed on the approved and required standardized query forms. Query forms should be kept as part of the permanent heath record according to hospital, state, and federal lawsrecord retention policy.
- Unanswered queries will be returned to coding professionals for follow-up with the provider on a post-discharge basis. CDS and Lead Coder will communicate via email.

Reporting

Queries will be tracked and trended to determine educational opportunities for providers based on the type, volume, and response to provider communication.