Tips for Compliant Medical Queries
Mastering Query Writing: Rules and Best Practices for Effective Communication in Coding
As healthcare professionals in the world of coding, we will all need to write a query at some point or another. Writing queries can be confusing and there are several rules surrounding the correct way to write a query. If coding and CDI specialists do not follow these rules, this can lead to physicians not understanding what the coder or CDI is asking so the query goes unanswered or not answered correctly, which can lead to the coder or CDI querying the physician multiple times. This could also impact reimbursement and lead to payers denying a claim for noncompliance. There are several reasons why CDI or a coder needs to send a query. These reasons can include conflicting, incomplete, or inconsistent documentation, associated clinical indicators related to a specific condition, to clinically validate a diagnosis, and if it is unclear if a condition was present on admission or not. These are all very good reasons to send a query and can help prevent a coder from assuming that is what the physician meant or making a connection in the documentation that does not exist. Both coders and CDI need to ensure that the query is appropriate before sending.
Yes, you can use quotation marks within a query if you are pulling specific information from the record as a direct quote when citing information in support of a query.
Provide pertinent data including vital signs, lab data, clinical indicators, and documentation from physician’s notes.
Queries should only include clinically relevant options (meaning those options that are supported by the clinical indicators within the health record) and exclude clinically irrelevant options.
Options must include the choice of “other” (or similar terminology) to allow the physician to customize their response for multiple choice answer options.
The option of “unable to determine,” is not synonymous to “possible” and does not follow the uncertain diagnosis guidelines.
You can include answer options (but are not required) of unknown, not clinically significant, integral to, unable to rule out, inherent to, or other similar wording
Be professional and use correct spelling and punctuation.
Reread your query and ensure that the query should be sent. Ensure that you were clear, and that the physician can answer it appropriately which allows you to make a complete and final decision on your coding.
Avoiding Noncompliant Queries: Ensuring Accurate Coding and Preventing Denials
To help prevent denials and to accurately code a diagnosis, it is important for coders and CDI to avoid sending noncompliant queries. Payers will deny claims and coders will get errors during quality audits if they are not following compliant query rules. Compliant queries are essential to ensure that clinical information is accurately captured in a patient’s health record. There are many things that can make a query noncompliant. Below are some examples that coders and CDI specialists should avoid:
Do not highlight or bold important information or clinical criteria.
Do not insert your own interpretation or diagnosis that has not yet been identified/documented.
Never tell the physician what to write or introduce new information that was never there.
Do not include impact on reimbursement, quality measures, or other reportable data.
Do not query if the physician cannot offer clarification based on the present health record documentation.
Do not query when documentation is present in the record that supports diagnosis coding.
Do not include leading or impactful information in the query title.
Do not send the same query to multiple physicians until the desired response is obtained.
Do not ask multiple questions on one query. This can be confusing and overwhelming to the physician and will often lead to only part of the query getting answered.
Understanding the "Unable to Determine" Option in Multiple-Choice Queries for CDI and Coding Specialists
When CDI and coding specialists write queries in a multiple-choice format, there are several options for the physician to choose from in their response. These options must be clinically supported and relevant to the patient’s encounter. Queries must include an option in the event that a physician is not able to provide an answer for the query. This option must include the choice of unable to determine or similar wording such as undetermined, not known, etc. When the physician chooses this option, it simply means that they are clinically unable to determine if the CDI or coding specialists’ question can be answered. Examples include further specificity of a diagnosis or if there is a diagnosis linked to the patient’s symptoms. The use of unable to determine in multiple choice queries can be confusing at times and it is important to understand its meaning when a physician answers a query with unable to determine.
Unable to determine is defined as the physician being clinically unable to determine if a diagnosis or further clarity can be provided in the documentation.
It is not the same as being unable to rule out or represent an uncertain diagnosis and therefore does not follow the uncertain diagnosis Official Coding Guidelines.
The option of unable to determine is required in POA and yes/no queries.
Does not need to be included in multiple choice query options unless querying for POA or organizational policy requirement.
Unable to determine options may be reviewed on a case-by-case basis to determine if further escalation of the query should be performed.
Defining Clinical Indicators: The Role of Physicians in Accurate Diagnosis Documentation
Many organizations and payers establish their own internal guidelines for what they consider to be clinical indicators that support coding a diagnosis. This can be helpful for CDI specialists and coders when identifying if a diagnosis is reportable or not but ultimately it is up to the physicians to determine what clinical indicators define a diagnosis and to ensure these are documented in the patient’s health record accurately. This includes ensuring clinical indicators are:
Clear and concise
Directly supporting the condition requiring clarification
Allowing the physician to clinically determine the most appropriate medical condition or procedure
Painting the clinical picture of the diagnosis queried to be added or clinically validated
Specific or directly related to, but not necessarily from the current encounter
Supporting documentation that will translate to the most accurate code
Clinical indicators can be found in many areas of the patient’s health record. Some examples of where these can be found include:
Emergency services documentation (e.g., emergency service transport, ED physician, ED nursing)
Diagnostic findings (e.g., laboratory, imaging)
Physician impressions (e.g. history and physical, progress notes, consultations)
Relevant prior visits (if the documentation is clinically pertinent to the present encounter)
Ancillary professional documentation and assessments (e.g., nursing, nutritionist, wound care, physical, occupational, speech, and respiratory therapist)
Procedure/operative notes
Care management/social services
Utilizing TRIC Queries for Compliant and Effective Physician Communication
A tactic that can be used to ensure the components of a query are being used and provided in a compliant manner to physicians is the use of TRIC queries. TRIC is an acronym that stands for treatment, risk, indicators, and compliant questions. Each component includes:
Treatment: According to the Official Guidelines for Coding and Reporting a condition must be monitored, treated, and evaluated, require increased allocation of nursing resources, or require an extended stay. When querying, treatment should be well documented.
Risk: Refers to the relevance of the diagnosis to the patient and the encounter for care. This does include signs and symptoms as the risk is being assessed.
Indicators: Refers to the clinical indicators that comprise the overall clinical picture and are pertinent to supporting or ruling out a diagnosis. It is important to include all clinical indicators when querying the physician to avoid noncompliant and leading queries.
Compliant Questions: The question should always be clear and concise without being leading. Be professional and use proper spelling and punctuation. This will help avoid any confusion and the physician asking for additional information or not responding at all.
Applying MEAT Criteria for Effective Documentation and Query Writing
Many organizations use the MEAT criteria to ensure their documentation meets the requirements for validating coding. The MEAT criteria can also be helpful when writing a complaint query using TRIC. When considering what treatment and resources were utilized for the patient, you can use the acronym MEAT to ask yourself what was done during the patient encounter.
Monitoring: Was the patient monitored in any way? Examples of monitoring would be: Repeat labs, documentation of signs and symptoms, and surveillance.
Evaluation: What type of evaluation was done? This would include any consultations received, physical exam findings, test results, medication effectiveness and treatment responses.
Assessment: Did the patient receive any assessment by physicians or nursing? An assessment of the patient would be a discussion and assessing of ordered labs, review of the records, counseling, ordering of further testing, serial neurological checks or vital signs.
Treatment: Did the patient receive any treatment? Treatment directed toward the patient would include any care being offered, continuation of medication, therapies, diagnostic studies, procedures, dressing changes, oxygen, and other modalities.
In summary, knowing when and how to properly write a medical query can have many impacts on a patient’s health record if not done properly. These impacts can include claims being denied, incorrect coding, missed reimbursement opportunities, and the correct and whole clinical picture not being accurately captured in a patient’s health record. A proper query process can help prevent noncompliance and ensure the complete and proper documentation appears in the patient’s health record.
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