July 2015

This Will Go On Your Permanent Record—Or Will It?
By Juliann Schaeffer
For The Record
Vol. 27 No. 7 P. 12

Experts discuss the pros and cons of including physician queries in medical charts.

Most would agree physician queries are a necessary and vital part of the documentation process, but where this particular piece of information should reside after it's been completed is a different story. In a recent Association for Healthcare Documentation Integrity survey, only 32.9% of respondents said they thought queries should be a part of the permanent patient chart.

The debate focuses on several issues, with reimbursement and physician satisfaction being chief among them. But no matter where a hospital sees fit to keep its queries, it seems the most important piece of the puzzle is to wind up with the best documentation possible.

Query Importance
According to Cheryl Manchenton, RN, BSN, project manager and quality services lead for 3M HIS Consulting Services, queries, which come in multiple forms (verbal, paper, and electronic are the most common), typically fall into three basic types: a query for information in which there's not already an associated diagnosis, a query for further specificity regarding a diagnosis, and a more generic category including linkage of conditions, present on admission status, or conflicting documentation.

A common communication tool amongst coders, clinical documentation improvement (CDI) specialists, and providers, queries are an important vehicle for gaining more clarity, completeness, consistency, legibility, or precision for the existing patient medical record, says Jillian S. Hubbard, RN, MPH, ACM, CCDS, CDI service line manager for Woodham HIM Solutions.

An effective query process can not only lead to better documentation but also improve data integrity overall, says Wendy Clesi, RN, CCDS, director of CDI services for Huff DRG Review. "High-quality health care documentation serves as a means of communication among all health care professionals involved in the care of the patient and is the foundation for continuity and quality patient care," she says. "Complete and accurate documentation supports code assignment, facility/provider reimbursement, resource utilization, medical necessity, and the quality of care being delivered."

But Where Do They Belong?
Queries may be a necessary part of the documentation process, not just for accurate reimbursement but also for patient care as a whole. But as queries are a documentation piece that's added outside of the typical physician documentation process, their place in the permanent medical chart—and whether they actually belong there in the first place—is up for debate. And hospitals are largely left to decide for themselves what works best.

"There's no clear guidance to whether or not a query should be a permanent part of the patient record," Clesi says. "The decision is left to each individual facility."

She notes that wherever it's deemed queries are to be stored, every hospital's query process should be designed based on the foundation of strong compliance with a focus on improving the data integrity of the health care record and patient care outcomes.

With this in mind, Clesi suggests hospitals make transparency a top priority when determining a home for queries. "If you're doing the right thing, the right way, and for the right reasons, there should be no reason to not include the query as a permanent part of the patient's record," she says.

Manchenton agrees on the importance of transparency, noting that if a hospital is truly compliant in its query process, there's nothing to fear from including them in the permanent record. "In alignment with the AHIMA/ACDIS [Association of Clinical Documentation Improvement Specialists] practice briefs that describe a compliant query process, we recommend that all queries should either be a permanent part of the record, or not," she says, noting that a mix between the two could raise red flags. "A process in which only some of the queries are included in the permanent record might indicate that there is something to hide. Transparency is essential, so if queries are compliant, then there should be nothing to hide and no reason not to include them as a part of the permanent medical record."

While organizations are free to determine the specifics of their query process, Cassi L. Birnbaum, MS, RHIA, CPHQ, FAHIMA, an ICD-10-CM/PCS trainer and ambassador and AHIMA board chair/president, says queries included in the permanent chart require more patient information than those that are not (those that are only part of the business record or are shredded after completion). But regardless of how a query is created, she says organizations must determine where to place the query within the chart and whether queries will be a part of the legal health record or designated record set. "In addition, whether or not to provide copies of the queries in requests to auditors should also be determined," she says, recommending that organizations seek the advice of legal counsel if they have specific questions pertaining to their facility's query retention.

Benefits of Inclusion
According to Manchenton, including queries in the permanent chart offers two main benefits: transparency and clarity. "Having queries be a permanent part of the medical record demonstrates the organization's commitment to transparency and an ethical query process," she says, noting that it also adds clarity to why a diagnosis was changed or made more specific during a patient's stay.

"For example, why would a provider start documenting sepsis when they didn't earlier in the stay?" she says. "A compliant query with all of the associated clinical indicators and treatment would support the provider's current determination of a sepsis diagnosis."

Furthermore, because all related documentation is available, questions have been clearly written, and clinical rationale was provided for all conditions, diagnoses, and procedures, the risk of denials is decreased, says Clesi, adding that including queries in the permanent chart also can increase physician satisfaction, which can result in improved response rates.

Audit Considerations
With regulatory demands on the rise and costly audits a greater concern, Clesi says including queries in the chart is the best way to ensure the most complete documentation and the most accurate billing. "This will ensure optimal and accurate reimbursement, accurate profiling scores, demonstrate true care delivery and quality outcomes, and reduce the risk of audits and denials," she says.

However, Birnbaum notes that not all audit reviewers will consider queries when determining whether a claim was appropriately billed. "It's usually at the discretion of the audit reviewer to determine whether they will accept a query to support the claim billed," she says, noting that some auditors don't consider query forms to be part of the health record.

Using queries to substantiate a particular code assignment can create problems. "When fulfilling audit requests, organizations should always submit all documents believed to have supported the claim, which may include the entire legal health record," Birnbaum says. "Organizations must determine the best approach when submitting queries as a part of a third-party audit and include a review of applicable local, state, and federal payment guidelines when considering submission."

To avoid such situations, Birnbaum says many organizations will ask providers to document answers in the progress notes or as an addendum to the discharge summary.

What do auditors typically look for in terms of queries? According to Birnbaum, they want to make sure physicians aren't led to higher-weighted MS-diagnosis-related group payments and there were clear clinical signs and symptoms documented by the physician prior to generating a query. "Consistently following AHIMA's best practice query process will hopefully minimize denial activity," she says.

The Importance of CDI
Because clinical documentation often is the impetus for third-party audits, Birnbaum says the need has never been greater to get all staff on board with sound documentation habits. "As the health care industry experiences a record number of external audits, both federal and private, the need to clearly articulate the patient's need for admission within the health record has become paramount," she says.

Having queries available for review—wherever they're stored—helps ensure continuity and foster good communication between departments, Hubbard says. For example, it allows hospital staff, including coders, to see postdischarge whether a question was posed concurrently so it's not asked again retrospectively. "This saves unnecessary rework for staff as well as increases physician satisfaction," Hubbard says. "If physicians were asked something and said no once, they don't want to be asked again."

While not including queries in the record may lead to more costly and time-intensive audits, Hubbard cautions that their inclusion will point out specific diagnoses being missed and draw attention to incomplete, nonspecific, and omitted documentation.

Hubbard, who's familiar with hospitals on each side of the query storage equation, says including queries in the permanent chart can benefit CDI efforts. "CDI staff can utilize specific query templates that are approved and compliantly written when placing a query, making it easier for the physician to understand what's being asked," she says. "Then, once the physician responds to the query, it then can be coded as written. There's no hunting or searching for the physician responses; they are clear and easily trackable."

Storing Queries Elsewhere
Although having queries readily available may not always help a particular audit case, Birnbaum says not having them could hurt more. "If the organization had a hard time defending the rationale for the determination of a diagnosis with a third-party auditor or accused the organization of leading the physician or following a noncompliant practice, the query form could be used to defend sound query practices," she says.

In addition to more maintenance and storage for retaining query forms elsewhere, not including them in the permanent chart could lead to other unintended consequences such as delayed physician response, Clesi says. "One of the most common and concerning practices that I've observed when queries are not maintained as a legal part of the medical record is how and where providers respond to the queries," she says. "It's often a one-word answer on a blank page or randomly inserted into a note in the medical record. The documentation typically appears out of context and in many cases has led to increased denials by outside reviewers."

When a query isn't maintained as part of the legal medical record, Clesi says the most recent AHIMA query practice brief puts the onus on the provider to complete a written or dictated addendum to the medical record, which may or may not be best the best way to ensure quality documentation.

However, Hubbard believes this may spur physicians to focus more on documentation. "The good part of not including the query in the medical record is that it forces the physician to document the diagnosis in the actual medical record, adding the appropriate diagnosis to a progress note or adding it to the patient's problem list and subsequently documenting a treatment plan, rather than just checking a box on a written query and having that be the only time a diagnosis is mentioned, which isn't best practice," she says.

Intricacies of Inclusion
The amount of effort necessary to include queries in the permanent record depends on the facility's environment. For organizations that are 100% electronic, queries are usually sent via the EMR, making them easy to retain, Manchenton says.

A hybrid record system, however, could prove troublesome, Birnbaum says. "Many EHR systems don't interoperate well with electronic systems and pose difficulties in assuring that queries are reviewed and approved, or rejected and signed," she says.

In a hybrid environment, Clesi says process design must be built around available resources with an emphasis on making it easy to complete queries. "EMRs have been a blessing in many respects, but have posed new challenges for entities that aren't completely electronic or haven't rolled out the electronic version to all of the medical staff," she says. "This may require setting up two separate query processes, one paper and the other to be submitted electronically."

If including queries in patient charts isn't in a facility's best interest, then it must prepare a retention schedule as part of an overall information governance plan, says Birnbaum, who recommends consulting legal counsel and risk management to go over any associated risks.

"If the queries are compliant, there should be no worries," says Manchenton, who notes that whether or not queries are a permanent part of the medical record, they still are subject to auditing.

October 1 Looms
While there are many opinions on how ICD-10 will affect the number of queries, Manchenton foresees an initial increase but not an onslaught. "First, many queries are not 'new' for ICD-10-CM/PCS but are modified to ensure all needed elements for full coding in ICD-10-CM/PCS are available," she says. "Secondly, CDI staff and HIM staff already rate the merit of their queries and prioritize those of the utmost importance so as not to overwhelm providers or make them 'query weary.'"

Whatever the case come ICD-10, Clesi says there's one thing we know for sure: "If you aren't getting it right in ICD-9, you won't get it right in ICD-10. While documentation for ICD-10 requires more specificity, which will lead to more queries, the query process itself should not be affected."

Wherever queries end up, Manchenton says it's important for facilities to adopt a written policy for how queries are handled (ideally incorporating AHIMA/ACDIS recommendations) and enforce compliance with those specifics. "I've seen denials related to the lack of appropriate queries and I suspect there will be further scrutiny," she says, "not just of the query itself but also of the organization's policies and procedures regarding queries. Processes have to be in place for periodic review to ensure compliance and adherence to the policy."

— Juliann Schaeffer is a freelance health writer and editor based in Alburtis, Pennsylvania.