September 10, 2012

Avoiding the Power of Suggestion
By Susan Chapman
For The Record
Vol. 24 No. 16 P. 18

Leading physician queries are a no-no and seriously frowned upon by auditors, but there are techniques to avoid being suggestive.

Queries are critical to clinical documentation improvement (CDI) and require cooperation between physicians and coding professionals to ensure medical records are clear and accurate. A 2008 AHIMA practice brief says, “The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation, accurate coding cannot be achieved. … Providers should be queried whenever there is conflicting, ambiguous, or incomplete information in the health record regarding any significant reportable condition or procedure.”

Specifically, AHIMA advises healthcare organizations to initiate queries when a patient’s record is illegible, incomplete, unclear, inconsistent, or imprecise. The AHIMA brief also recommends that queries themselves be precise, offer clinical indicators that already exist in the record, and request that the provider use those indicators when giving an interpretation of the data. Queries can be concurrent, or initiated while the physician is treating the patient; retrospective, or launched after the patient is discharged but before a bill is sent for reimbursement; postbill, or begun after the bill has been submitted; or a combination of the three.

Presumptions Not Allowed
Despite a solid knowledge base, coders and clinical documentation specialists are not in a position to make conclusions about a patient’s status. “Medicare clearly states that coders are not physicians. Therefore, the attending physician must be the one to close the loop on missing data,” says Kathryn DeVault, RHIA, CCS, CCS-P, director of HIM solutions at AHIMA. “For instance, if the physician orders a urinalysis that comes back positive for growth and orders an antibiotic, she must give the diagnosis. The coder simply cannot assume the patient has a urinary tract infection and code for that diagnosis.”

Though a coder may suspect a diagnosis based on clinical indicators, queries may not lead the physician to a specific conclusion. “Queries that appear to lead the provider to document a particular response could result in allegations of inappropriate upcoding,” according to the AHIMA brief. “The query format should not sound presumptive, directing, prodding, probing, or as though the provider is being led to make an assumption.”

If a coder were to take action, the consequences could be serious. “Bills that are turned in for healthcare payers have ICD codes to ensure reimbursement, demonstrate how ill the patient is to justify that reimbursement, and enter into the database all healthcare information about a patient so that any potential new provider would have a clear understanding of the patient’s medical history,” says Robert S. Gold, MD, CEO of DCBA, a CDI education company. “If the coder leads the physician to an inaccurate diagnosis, then all that follows will be inaccurate as well.

“Leading query problems began with the inpatient prospective payment system,” he adds. “Before computers, medical record librarians used books for ICD codes and assigned DRGs [diagnosis-related groups] to the cases. Coders learned how to look through the medical record and found indications of what could be there. They came under fire because they coded for something that wasn’t actually documented by a physician in the record, coding instead for what they thought, based on the indicators, even though that may not have been the actual diagnosis.”

Gold explains that coders began to recommend diagnoses to doctors, who often followed the advice to expedite the process even though the coders were incorrect. “Ultimately, these inaccuracies cost Medicare and Medicaid billions of dollars each year,” he says. “Investigations by the Office of Inspector General, state peer review organizations, quality improvement organizations and, more recently, the recovery audit contractors [RACs] are leading to recoupment of such errors and others.”

It helps not to be too forward when querying a physician, DeVault says. “The coder has to beat around the bush when drafting the query, and the question has to be open ended or multiple choice,” she says. “But in the end, the purpose of the query is to improve or make correct the documentation, A plus B equals C is reflected in the coding, the patient is treated appropriately, and the facility is reimbursed appropriately.”

The prevalence of auditors in today’s hospital environment adds to the significance of appropriate queries. “The regulatory environment has heightened the issue,” says Teresa Engel, RN, CCS, CDIP, corporate director of CDI services at United Audit Systems, Inc. “I always tell clinical documentation specialists to be prepared to defend your query no matter how careful you are.”

Engel believes that because physicians aren’t familiar with coding terms, they have a right to know their choices. “They get frustrated,” she says. “And we shouldn’t feel the need to hold back. Providers should put the most correct diagnosis into the record, and the query must bring about the most correct and effective diagnosis.”

Engel calls AHIMA’s 2008 brief the most comprehensive body of knowledge available on queries. “The biggest thing that came out of 2008,” she says, “is that we could offer choices to physicians and it isn’t considered leading. It’s not leading if we give the physicians choices, list the clinical indicators, and name some diagnoses that are clinically reasonable. But we also need to give the physician the choice of ‘nonapplicable’ and ‘disagree.’”

Juli Bovard, a registered nurse and a certified clinical documentation specialist at South Dakota’s Rapid City Regional Hospital, uses a similar process to obtain the most accurate information. She plays a crucial role in the query process, reviewing Medicare patient records and serving as a liaison between physicians and coders to ascertain the physician’s thought process when treating patients and recording data.

“The physician documents the case and the clinical documentation specialist checks the record for clarity and quality. The coder does the same thing as the clinical documentation specialist but is looking at numbers—the codes and reimbursements,” Bovard says. “Our role as clinical documentation specialists is to ensure that if someone else looks at the chart down the road, one would know exactly what was wrong with the patient.”

With ICD-10 on the horizon, Bovard notes, what now has two or three codes will soon have 200. “So it’s important that clinical documentation specialists get the physicians to be as specific as possible to ensure proper coding,” she says.

Bovard believes it is important to remain credible to providers. “Clinical documentation specialists have to build a rapport with doctors. While we would never question a physician’s diagnosis, we can’t be afraid to ask questions if something is unclear. Still, doctors have to respect us,” she says. “If we ask questions that have no basis or background, we will lose physicians’ respect, and we’re less likely to earn their cooperation.”

Verbal Queries and Templates
Engel says nurses are most comfortable giving verbal queries. “Verbal queries are less formal,” she says. “Still, I would urge all hospitals to show that there are standards in place so that verbal queries are carried out in a nonleading way yet still effective. Additionally, hospitals need to demonstrate that they have policies in place for written and verbal queries in the regulatory world.”

Engel and Bovard agree that in certain circumstances templates make excellent query tools. Some EHRs have query forms built into the system, enabling the query to immediately become part of the permanent record. However, not all facilities have such programs available.

“We did a systematic breakdown of the top things we were querying for, and we created templates for those queries,” Bovard explains. “For instance, in the case of sepsis, septicemia, or bacteremia, we ask the physician to please clarify which one it is. We offer choices and also ‘other’ and ‘undetermined.’ We never want our queries to sound presumptive, prodding, or probing, in keeping with AHIMA recommendations.”

Although Rapid City Regional Hospital uses specific templates for corresponding queries and diagnoses, their use is limited to certain circumstances. “We can only use a specific type of query if the physician actually uses the word in a diagnosis,” Bovard says. “For instance, even if the clinical documentation specialist suspects the diagnosis is anemia, if the physician doesn’t use the word anemia in the record, the clinical documentation specialist cannot send the anemia query form.”

Templates are becoming a popular item, Engel says. “Clients clamor for templates and forms, which are time saving for common things, and they don’t always have them available in their existing systems,” she notes. “They want forms that give clinical indicators. Templates can be helpful, but I always recommend that hospitals’ internal counsel review those forms and sign off on them so that they are in compliance.”

Consequences of Leading Queries
The Medicare Recovery Audit Program, which the Tax Relief and Health Care Act of 2006 made permanent in all 50 states, helps identify improper Medicare payments. Working on a contingency basis, RACs earn a percentage of the overpayments they collect. RAC audits can go back three years and can review costs such as hospital stays, outpatient care, physician services, and other medical services. According to the Centers for Medicare & Medicaid Services (CMS) website, during the RAC demonstration period from March 2005 to 2008, the program succeeded in returning more than $990 million in overpayments to the Medicare Trust Fund and nearly $38 million in underpayments to providers.

Engel says the consequences of leading queries are severe. “The harshest consequence is fraud. The next worst-case scenario beyond that is that CMS will take the money back in part or in full,” she says. “Then on top of losing reimbursement, you have now invited all other healthcare patrols into your hospital. If there is a charge for leading queries, it goes beyond one case. Queries will have to be defended, but the good news is there are levels of appeal. We’ve gotten many reversals at higher levels of appeal. The RAC can say it’s a leading query, all or part of the payment can be revoked, and then that decision can be appealed.”

The Value of Education
Engel, Gold, and Bovard agree that educating staff is an integral part of an effective query process. “We can’t teach in the moment, but periodically we can offer information in an educational setting,” says Engel, who occasionally enlightens physicians on unfamiliar coding guidelines and clinical terms they use that do not correspond to existing codes. “For example, HAP, or healthcare-acquired pneumonia, means nothing in the coding world,” she says. “We have to let physicians know how best they can communicate with coders. If we educate physicians proactively, then they and the coders have a much easier time with queries.”

Living in the Permanent Record
About a year ago, Rapid City Regional Hospital decided to make queries a permanent part of the medical record. “It’s a good process,” Bovard says. “You can see the tracking of how the diagnosis arrived in the record.”

Engel says the facilities she works with are split on whether to include queries in the permanent record. “Obviously, it’s OK if the query is discarded because the physician ultimately creates the record. However, some hospitals keep records,” she says. “I highly recommend that counsel have input in that area. In fact, when making such a decision, counsel, compliance officers, and risk management should all sign off on the policy.”

As facilities move from paper records to electronic systems, the transition will probably affect the query process. “Queries will be much easier when hospitals are using only electronic health records,” Bovard says. “As an industry, healthcare is moving at light speed to be 100% electronic. Until then, though, the query process is a struggle.”

Engel believes cooperation is the key to successful queries. “Ensuring that the record is accurate requires a multidisciplinary approach,” she says. “The process needs to include coders, clinical documentation specialists, physicians, counsel, and the risk management team. When everyone works together, it makes the facility less vulnerable. That said, though, in my career, I’ve worked with more than 300 hospitals, and I’ve seen only one facility that had what I would term a leading query risk pattern. I’ve not been aware of any hospitals that have been penalized and yet we have to spend so much time and energy. That, to me, is profound.”

— Susan Chapman is a Los Angeles-based writer.