Compliant Query Guidelines
What is a query?
- A query is a communication tool used to clarify documentation in the health record for documentation integrity and accurate code assignment for an individual encounter in any healthcare setting. - Queries are used by coding professional, CDI professionals, and all professionals responsible for documentation clarification or who have oversight and/or involvement in the query process - All queries, including verbal queries, should be memorialized to demonstrate compliance with all query requirements to validate the essence of the query
Clinical Indiactors
- CLINICAL INDICATORS is a broad term encompassing documentation that supports a diagnosis as reportable and/or established the present of a condition. Examples of clinical indicators include: provider observations (Physical Exam and assessment), diagnostic findings , treatments, etc. provided by providers and ancillary professionals. There is not a required number of clinical indicators that must accompany a query because whet is a "relevant" clinical indicator will vary by diagnosis, patient and clinical scenario - When the purpose of the query is to add a diagnosis, clinical indicators should clearly support the condition, allowing the provider to identify the most appropriate medical condition or procedure. The quality of clinical indicators - how ell they relate to the condition being clarified - is more important that the quantity of clinical indicators
Noncompliant Examples
- Directing a provider to document a diagnosis that is not clinically supported but serves as an exclusion for a patient safety indicator - Adding a non-reportable diagnosis - Encouraging a provider to neutralize documentation suggestive of a post-surgical complication - Organizations should educate all relevant professionals in compliant query practices through collaboration with health information management, coding and CDI professionals
Query Criteria
- QUERIES NEED TO MEET ALL OF THE FOLLOWING CRITERIA: - Be clear and concise - Contain clinical indicators from the health record - Present only the facts identifying why the clarification is required - Be compliant with the practices outlined in this brief - NEVER include impact on reimbursement or quality measures
Why Query?
- Queries are utilized to support the ability to accurately assign a code and can be initiated by either coding or CDI professionals. Queries may be necessary in (but are not limited to) the following instances: - To support documentation of medical diagnoses or conditions that are clinically evident and meet Uniform Hostial Discharge Date Set (UHDDS) requirements but without the corresponding diagnoses or conditions stated - To resolve conflicting documentation between the attending provider and other treating providers (whether diagnostic or procedural) - To clarify the reason for inpatient admission - To seek clarification when it appears a documented diagnosis is not clinically supported - To establish a diagnostic cause-and-effect relationship between medical conditions - To establish the acuity of specificity of a documented diagnosis to avoid reporting a default or unspecified code - To establish the relevance of a condition documented as a "history of" to determine if the condition is active and not resolved - To support appropriate Present on Admission (POA) indicator assignment - To clarify if a diagnosis is ruled in or out - To clarify the objective and extent of a procedure
Compliant Query Practice
- Queries must be accompanied by clinical indicator(s) that: - Are specific to the patient and episode of care - Support why a more complete or accurate diagnosis or procedure is sought - Support why a diagnosis requires additional clinical support to be reportable - Avoid the qualifier "possible" in the formation of the query question - Avoid queries that: - Fail to include clinical indicators that justify the query - Encourage the provider to a specific diagnosis or procedure - Indicate the impact on reimbursement, payment methodology or quality metrics
How to query
- Verbal, written paper, and electronic queries serve the purpose of supporting clear and consistent documentation of diagnoses being monitored and treated during a patient's healthcare encounter. Regardless of the method, a query must adhere to compliant, non-leading standards, permitting the provider of record to unbiasedly respond with a specific diagnosis or procedure. References to reimbursement must not occur. All relevant diagnoses, lab findings, diagnostic studies, procedures, etc. which illuminate the need for a query should be noted. - Regardless of the format and technology used, a query should not direct the provider to document a specific response. Best practice dictates that, whenever possible, query responses be consistently documented withing the health record as part of the progress notes and discharge summary or as an addendum as appropriate. If a compliant query has been properly answered and authenticated by a responsible provider and is part of the permanent health record, absence of the documented answer in a progress note, discharge summary, or addendum should not prohibit code assignment.. - A providers response to a query should be documented in the health record even if the patient has been discharged.
Introduction to Queries
- With the evolution of reimbursement methodologies that move beyond resource use and instead focus on severity of illness, medical necessity, risk adjustment, and value-based measures, specific documentation related to diagnosis capture, acuity and clinical validity have become even more important - The need for clear and accurate documentation and how it is translated into claims data impacts healthcare roles such as case management, quality management professionals, infection control clinicians and others
Written Queries
- Written paper and electronic queries are to be constructed in a clear and concise manner citing relevant clinical indicators and identify applicable diagnoses that are fundamental for the provider to accurately respond. Queries should be legible and grammatically correct. All clinically supported options should be included as well as additional options that permit the provider to craft their own alternate response. Options may include other, unknown, unable to determine, not clinically significant, integral to, or other similar wording. - Written queries can have the following format: - OPEN-ENDED: The provider free texts a response which may or may not align with documentation needed to support code assignment - MULTIPLE CHOICE: Multiple choice query formats should include clinically significant and reasonable option(s) as supported by clinical indicator(s) in the health record, recognizing that occasionally there may be only one reasonable option. There is no mandatory or minimum number of choices necessary to constitute a compliant multiple-choice query. - YES/NO: Yes/No Queries should only be employed to clarify documented diagnoses that need further specification. Yes/No queries may not be used in circumstances where only clinical indicators of a condition is present, and the condition/diagnosis has not yet been documented in the health record. The query should include the documentation in question with relevant clinical indicators and be constructed so that it can be answered with a "yes" or "no" response. --Some examples for when a yes/no query may be applicable: - Determining a POA status - Substantiating a diagnosis that is already present in the current health record (i.e., findings in pathology, radiology and other diagnostic reports) with interpretation by a physician - Establishing or negating a cause and effect relationship between documented conditions such as manifestation/etiology, complications, and conditions/diagnostic findings - Resolving conflicting documentation from multiple providers
Explanation of the Role of Prior Encounters in Queries
AHA ICD-10-CM/PCS Coding Clinic's Third Quarter 2013 section "Assigning codes using prior encounters" states "When reporting recurring conditions and the recurring condition is still valid for the outpatient encounter or inpatient admission, the recurring condition is not documented in the current health record it would be inappropriate to go back to previous encounters to retrieve a diagnosis without physician confirmation." A query may be initiated to clinically validate a diagnosis that a prior health record provided evidence to support particularly when clarifying specificity or the presence of a condition which is clinically pertinent to the present encounter supporting accuracy of care provided across the healthcare continuum. Prior encounter information may be referenced in queries for clinical clarification and/or validation if it si clinically pertinent to the present encounter. However, it is inappropriate to "mine" a previous encounter's documentation to generate queries not related to the current encounter
Example #1: Diagnosis is documented, but not clinically supported
Patient Name: Dear Doctor, Acute respiratory failure was documented within the H&P dated xx/xx and the progress notes dated xx/xx and xx/xx. Clinical Indicators:Underlying pneumonia, respiratory rate of 12 without use of accessory muscles of respiration, and arterial blood gases revealing a pH of 7.40, pCO2 of 36, and pO2 of 75 on room air as documented in the H&P. Based on your judgement and review of the clinical indicators, can you please select the most appropriate diagnosis below? Pneumonia without acute respiratory failure Pneumonia with acute respiratory failure (if confirmed, please add additional supporting information in the health record) Other explanation of clinical finding (please specify) ___________________ Clinically undetermined
Example #4: Medical diagnosis that is clinically evident
Patient Name: Dear Doctor, O2-dependent COPD was documented within the H&P dated xx/xx. Clinical Indicators: Respiratory therapy dated xx/xx notes patient on continuous home O2 at 2L/min and continued during hospitalization. Based on your judgement and review of the clinical indicators listed below, can you please select the most appropriate diagnosis? O2-dependent COPD with chronic respiratory failure O2-dependent COPD without chronic respiratory failure Other explanation of clinical findings (please specify) ___________________ Clinically undetermined
Example #5: Uncertainty of a cause-and-effect relationship between related conditions
Patient Name: Dear Doctor, Pancytopenia was documented within the progress note dated xx/xx. Clinical Indicators: H&P identifies the presence of lung cancer with bone metastasis, undergoing chemotherapy. Based on your judgement and review of the clinical indicators listed below, can you please select the most appropriate diagnosis? Pancytopenia due to chemotherapy Pancytopenia due to other cause (please specify): ______________ Pancytopenia, etiology unknown Other explanation of clinical findings ________________________ Clinically undetermined
Example #2: Documentation in the present and prior health record provides evidence to support the presence of a condition
Patient Name: Dear Doctor, The current lab findings indicate an eGFR range of 17-20 mL/min. Clinical Indicators: Previous encounter note dated xx/xx documents CKD stage 4, previous lab findings over that last 3 months note an eGFR of 17-20 ml/min. Based on your judgement and review of the clinical indicators listed below, can you please select the most appropriate diagnosis? CKD, stage 4 Other explanation of clinical findings (please specify) ______________________ Clinically undetermined
Role of Prior Encounters in Queries
Queries using information from prior encounters may be utilized when relevant in the following situations (but not limited to): - Diagnostic criteria allowing for t epresence and/or further specificity of a currently documented diagnosis (e.g., to ascertain the type of CHF, specific type of arrhythmia) - Treatment/clinical criteria or diagnosis relevant to the current encounter that may have been documented in a prior encounter - Determine the prior patient baseline allowing for comparison to the current presentation - Establish a cause-and-effect relationship - Determine the etiology, when only signs, symptoms, or treatments are documented - Verify POA Indicator Status - Clarify a prior history of a disease that is no linger present (e.g., history of a neoplasm)
