A supplement to CDI Journal

Survey Says: Use CDI Best Practices

to Query Physicians

Survey Says: Use CDI Best Practices to Query Physicians2

Some programs query using both methods, says Garri L. Garrison, RN, CPC, CMC, CPUR, director of acute care services at 3M Health Information Systems Consulting Services in Atlanta. One program might employ primarily nurses, another might employ primarily coders, and a third might have a range of professional experience in its staffing mix. (Note: In the second quarter of this year, ACDIS will release a survey to benchmark industry expectations regard-ing the structure of CDI programs.)

However, the large number of respondents (29%) in question one who said they query physicians/providers retrospectively (postbill) somewhat surprised Garrison.

“It seemed somewhat old school,” she says. Retrospective queries open up audit opportunities. Anytime you rebill, you say to the fiscal intermediary, ‘Okay, come visit us.’ ”

Most facilities regularly perform all three types of que-ries, Bryant says, and HIM staff members typically receive requests from various departments for all three. Although

Physician queries are the backbone of any CDI pro-gram. But industry standards are hard to pin down. Some unanswered questions include:

What should you query? »When should you query? »How should you query? »Why should you query? »What information do you need to track once physicians »respond? What’s the best way to track CDI information? »And oh, by the way, how often do you do all this? »

With new CDI programs starting every day, profes- sionals need to know how to handle the physician query process.

To that end, ACDIS launched its physician query benchmarking report in January. The 20-question survey received 350 responses on a wide range of physician query concerns.

The answers show that CDI programs increasingly employ a concurrent review process. It also shows that although earning physicians’ support may be difficult in many situations, garnering their cooperation for CDI is an achievable reality.

“This certainly gives us some food for thought,” says Gloryanne Bryant, BS, RHIA, RHIT, CCS, senior direc-tor of systemwide coding and HIM compliance at Catholic Healthcare West in San Francisco.

When to queryThe first few survey questions covered the basics of the

query process: Do your specialists query concurrently or retrospectively, and which professionals most frequently perform which tasks?

Those who queried concurrently primarily employed clinical staff members from nursing and case management and/or physician advisors to lead their CDI program. Conversely, as shown by participants’ responses to question four, when the CDI program performed queries postdis-charge, HIM/coding staff members more frequently per-formed the task.

Benchmark report

ACDIS survey answers specialists’ physician query questions

Don’t drop the ball on the definition of ‘dropping the bill’

Here’s what a few ACDIS board members have to say about

the phrase:

“Dropping the bill” means sending the bill to the payer by »electronic means or via printing and mailing, depending on the

payer’s requirements, says Heather Taillon, RHIA, manager of

coding compliance at St. Francis Hospital in Beech Grove, IN.

“Dropping the bill” means the account has been coded and is »ready to go to the payer, says Jean S. Clark, RHIA, service

line director for HIM at Roper Saint Francis Hospital in

Charleston, SC.

“Dropping the bill” means that when the billing department »receives a coded claim that has completed its billing processes,

it enters the bill electronically or sends it to the printer for

remittance. This action earned its name because the depart-

ment printed the bill, put it in an envelope, and “dropped it into

the mail,” says Pam Lovell, MBA, RN, regional director, clinical

intake team, case management, Humana, Inc., in Louisville, KY.

April 2009 3

CDI implementation allows for more active concurrent reviews of documentation and there may be a subsequent decrease in prebill or retrospective queries, don’t expect either query type to disappear anytime soon, she says.

At DCH Health System in Tuscaloosa, AL, CDI staff members perform all concurrent and prebill queries, says Robin R. Holmes, RN, MSN, DCH Health System’s CDI manager. However, the HIM department also examines every patient record to determine whether any additional documen-tation needs remain.

“HIM looks at every account, and if they need more information, they ask the CDI [specialist] to provide addi-tional queries.” Holmes says. “They have the sequencing experience, they have the coding experience; if the coder feels there’s still a question, they bring the charts back to the CDI [specialist] before the bill gets dropped.”

Note: See p. 9 for a complete breakdown of the survey question and their results.

What to clarifyThe top reasons to ask a physician for further explana-

tion remain consistent with industry best practices, says Bryant. The highest number of respondents (96%) said they would query a physician if the medical record included continued on p. 4

AHIMA brief directs facilities to create query policies and procedures

In September 2008, AHIMA released “Managing an Ef-

fective Query Process,” an update to its 2001 practice guide-

lines “Developing a Physician Query Process.” The following

comes from that 2008 release.

Healthcare entities could consider a policy in which

queries may be appropriate when documentation in the

patient’s record fails to meet one of the following five

criteria:

Legibility. » This might include an illegible handwritten

entry in the provider’s progress notes, and the reader

cannot determine the provider’s assessment on the date

of discharge.

Completeness. » This might include a report indicating

abnormal test results without notation of the clinical

significance of these results (e.g., an x-ray shows a

compression fracture of lumbar vertebrae in a patient

with osteoporosis and no evidence of injury).

Clarity. » This might include a patient diagnosis noted without

statement of a cause or suspected cause (e.g., the patient is

admitted with abdominal pain, fever, and chest pain, and no

underlying cause or suspected cause is documented).

Consistency. » This might include a disagreement between

two or more treating providers with respect to a diagnosis

(e.g., the patient presents with shortness of breath. The

pulmonologist documents pneumonia as the cause, and the

attending documents congestive heart failure as the cause).

Precision. » This might include an instance where clinical reports

and clinical condition suggest a more specific diagnosis than is

documented (e.g., congestive heart failure is documented when

an echocardiogram and the patient’s documented clinical

condition on admission suggest acute or chronic diastolic

congestive heart failure).

Source: AHIMA, “Managing an Effective Query Process.”

evidence to warrant coding to a higher degree of specific-ity or severity. “There’s no surprise there, since there’s a gap between the physician medical terminology and that used for ICD-9-CM coding,” says Bryant.

Among the respondents, 95% said they’d query the phy-sician if the documentation included clinical indicators of a diagnosis, but the physician did not document that condition specifically.

The third highest response came from those who said they would query the physician if he or she documented a treatment but not a diagnosis. Other responses essentially tied for last place, with roughly 85% suggesting they’d query if:

The cause-and-effect relationship between two conditions »was unclear in the documentationThe physician neglected to determine the underlying cause »of the patient’s documented symptomsInconsistencies existed in the documentation of different »physicians

Question five was open-ended. It asked participants to describe a situation in which the CDI specialist should not

Survey Says: Use CDI Best Practices to Query Physicians4

Nearly 60% of respondents said leaving the query in the patient’s medical record was the most effective way to receive a response. Handing the query form directly to the physician earned second place (43%) as the most effective method, followed by 34% of respondents who suggested handing the query form to the physician assistant as the best way. Sending the physician a fax to his or her office was less effective, and e-mailing came in last as the least effective method.

Question six did not address vendor-related electronic medical record (EMR) query applications, says Garrison, noting that EMRs and electronic query systems have gained momentum since President Barack Obama signed a health information initiative into law in the American Recovery and Reinvestment Act of 2009.

Anecdotally, most successful CDI programs employ many techniques to make sure the physicians see and respond to the query, Holmes says. (Note: See p. 8 for analysis of physician query response rates.)

In question seven, nearly all respondents—ranging from 63% to 97%—said they incorporated standard elements such as those outlined in the AHIMA brief into most query forms in their systems. The only variation—and thankfully so, says Bryant—was the low number of respondents who

query the physician. Respondents essentially said that they would not query the physician under any of the following circumstances:

There is no clinical evidence in the documentation to »support the queryThe query would not affect the coding of the chart »The physician has already documented the patient does »not have that condition Querying more than once (e.g., concurrent and prebill) »if the first query answered the initial questionThe query aims only to increase reimbursement »There are no clinical criteria to support the query »The query includes anything leading the physician to a »diagnosis

How to queryQuestions six and seven illustrate physician query best

practices outlined in the September 2008 AHIMA prac-tice brief “Managing an Effective Query Process,” says Bryant.

Question 6

ACDIS surveycontinued from p. 3

April 2009 5

“Due to the changing needs of the query process, you’d want to at least periodically reassess your facility’s query forms,” says Bullock.

CDI specialists split nearly 50-50 in response to ques-tion 10, regarding whether they had a verbal query policy and procedure in place. The response may be due to con-fusion about the question, Bryant suggested. Most facilities have set policies and procedures regarding physician queries overall but do not separate their process for verbal queries, she says.

Regardless of whether your CDI program maintains a distinct policy and procedure for verbal query behavior, there should be consistency across the board, says Bullock.

The physician should know what to expect regardless of how staff members present the query (e.g., verbally, on a separate sheet in the patient record, or via e-mail). This consistency also helps CDI programs track physician res-ponse results.

In its brief, AHIMA acknowledged the increasing use of verbal and concurrent queries, although it did not state whether documentation specialists should record these types of queries in a permanent fashion.

“In my experience with CDI programs, somewhere within the mechanism of the program, you should be able to docu-ment that you visited with Dr. Smith on a certain date and that you had a conversation,” Kathy DeVault, RHIA, CCS, manager of professional practice resources at AHIMA in Chicago, previously told ACDIS.

Most respondents to question 11 (54%) said they used the AHIMA brief and previous CMS guidance to draft their policies and procedures. The next top source for query policy input was consulting firms (36%). Thirty-five percent of respondents said their policies were created by the CDI department alone. Only 29% said they used input from a col-laborative group of hospital departments.

said they put MS-DRG information or the dollar amount for patient services on their query form—20% and 1%, respectively.

“Attaching a dollar amount to the query form is just a no-no,” says Bryant. “We don’t do that in our organization. We avoid tying the documentation to reimbursement within the query form.”

How to regiment query proceduresTo avoid falling into compliance traps, many CDI pro-

grams invite input from other departments when standardizing their query forms. Question eight asked survey participants to name other departments that helped in this endeavor.

As expected, the highest involvement went to coding staff members, followed by input from nursing, case management, physician advisors, and the legal department. Roughly 62% answered “other”; responses in this category included con-sulting firms and compliance officers.

“Many new CDI programs inherited their query form from the consulting firm that helped [them] get off the ground,” Garrison says.

Nevertheless, “one might expect to see a higher involve-ment from the compliance staff in the creation of the physi-cian query form,” says Shelia Bullock, RN, BSN, MBA, CCM, manager of clinical documentation services at the University of Mississippi Medical Center in Jackson.

To question nine, regarding how often query forms receive review, most facilities answered quarterly, whereas 27% said they do not review their query forms at all.

The low rate of query review could be attributed to the relative newness of CDI programs, Bryant says; the younger a program, the less uniform its review process may be. Her facility formally reviews query forms during an annual review process for compliance, coding, format-ting, language, and clinical changes. Further, Bryant’s coding HIM compliance team conducts annual audits and reviews to determine whether any overall alterations need to be made.

continued on p. 6

“ Due to the changing needs of the query process, you’d want to at least periodically reassess your facility’s query forms.”

—Shelia Bullock, RN, BSN, MBA, CCM

Telephone: 781/639-1872, Ext. 3711

E-mail: mvarnavas@hcpro.com

Have more query questions?

Contact Associate Director Melissa Varnavas

Survey Says: Use CDI Best Practices to Query Physicians6

surprised by how many [people] do not keep the queries in the chart,” Bryant says.

If an auditor sees a sudden change in diagnosis in the medical record without additional query information, it might raise questions about compliance and leading queries.

“Without the query form in the record, you may not know what the information was based on,” Bryant says. “My guess is that these [respondents] are requesting addi-tional documentation within a progress note as an adden-dum or something similar.”

Others say a central tracking database and maintenance of query forms within the CDI department satisfy docu-mentation needs. If that’s the case, make sure your CDI poli-cies and procedures are clear. Define what will be kept and for how long. Also, describe how you will connect queries to medical records in the event recovery audit contractors (RAC) come to seek additional clarification.

Those who did not use the AHIMA brief for guidance may have already had their policies and procedures in place prior to the brief’s release, Bryant suggests.

In answer to question 12, 41% of survey participants said they document verbal queries in a central database or spreadsheet; 21% said they document the verbal inter-action in the case management utilization review work-sheet. Only 12% said they do not document verbal queries at all; even less, 5%, said they leave a note in the medical record.

However, the practice of leaving a note in the medical record is changing, and by this time in 2010, CDI programs may see a higher number of queries kept in the medical record. Skipping to question 16, only 28% of respondents said they kept queries as part of the medical record. “I’m actually

ACDIS surveycontinued from p. 5

Question 15

Other (please specify)

Initial DRG

Room number of patient

Name of staff member performing query

Type of physicial response

Name of physician

Working DRG

Number of days followed

Description of follow-up if necessary

Origin of inquiry (i.e., CDI specialist or coding staff member)

Date of physician response

Method of quesry (i.e., written or verbal)

April 2009 7

Statement of the issue in the form of a question, along »with clinical indicators specified from the chart (e.g., history and physical states urosepsis, lab reports white blood cell count of 14,400, and emergency department reports fever of 102º)

In addition, AHIMA states that “it is not advisable to record queries on handwritten sticky notes, scratch paper, or other notes that can be removed and discarded.”

Only 7% of respondents said they did not have an in-ternal mechanism for tracking physician queries. Although Bryant says that’s a good number, she adds that all CDI pro-grams should track responses. She calls the overall responses to the question “consistent” with industry expectations.

It’s interesting to note that the highest responses to question 17 (shown below) pertained to the effect of the CDI program on the facility. Seventy-nine percent

When tracking verbal queries, most respondents said they document the physician’s name, the CDI specialist’s name, the query date, a paraphrase of the question, and a paraphrase of the answer.

What to trackIn question 15, the survey asked what elements the query

tracking forms contain. The survey shows that most CDI programs follow advice from the September 2008 AHIMA guidance.

It states that queries should generally include the follow-ing information:

Patient name »Admission date and/or date of service »Health record number »Account number »Name and contact information of the individual initiating »the queryDate query was initiated » continued on p. 8

Question 17

Other, please specify

Percentage of positive and negative query responses

Severity of illness/other effect of queries

Financial effect of queries

Rates of queries administered to individual physician groups/departments

Rates of queries administered to individual physicians

Rates of queries issued by CDI specialist

Leading queries

Unnecessary queries

Survey Says: Use CDI Best Practices to Query Physicians8

Most CDI professionals want to know how other facilities fare in getting physicians to respond to queries. In response to question 18, 19% said they have an 81%–90% response rate, followed by 17% with a 71%–80% response rate. (See the graph below for additional information.)

Thirteen percent of respondents say they’ve achieved a 96%–100% response rate. That’s not completely unexpected, Garrison says; she argues that the best results come from CDI programs that give ownership of the query to a single individual. “When they know they get the query back even if it’s postdischarge, they make sure to get the query right the first time,” she says.

“Some programs have seen really good response rates,” Bryant says. “It’s good news. It’s proof that the system can really work. The next step is to examine those responses and make sure they matter” to patient care.

of respondents said they audit and monitor the percent- age of positive and negative physician responses to the query, 71% said they audit the financial effect of the query, and 70% said they audit the rates of queries by CDI specialist.

However, when looking at question 20, only 18% said they ask for help from the compliance department to audit their queries.

“This is surprising to me with the RAC coming,” Bryant says. “I would think that you’d want that extra set of eyes on your process and forms to make sure what you’re doing is accurate and captures everything it needs to without evoking any undue risk.”

ACDIS surveycontinued from p. 7

Question 18

Under 40% 41–50% 51–60% 61–70% 71–80% 81–90% 91–95% 96–100% Other, please specify

April 2009 9

Editor’s note: Due to space considerations, answers to open-ended responses were not included. For complete results of question five or other open-response answers, e-mail mvarnavas@cdiassociation.com.

1. When do you query physicians/providers or seek documentation clarification (check all that apply)?

Concurrently 320 92%Prebill (after discharge) 215 62%Retrospectively/postbill 101 29%Other (please specify) 7 2%

2. If your facility performs concurrent queries, do you use clinical staff members (e.g., nursing, case management, or physicians) to perform this function?

Yes 254 75%No 49 14%Don’t know 2 1%Other (please specify) 56 16%

3. When the query process is performed prebill or after discharge, who performs this function?

Clinical staff 96 28%HIM/coding 273 79%Other (please specify) 54 16%

4. Do your queries ask for clarification if (check all that apply):

The physician includes clinical indicators of a diagnosis but doesn’t document the condition 330 95%There is clinical evidence for a higher degree of specificity or severity 335 96%There is an undocumented cause-and-effect relationship between two conditions 301 86%The physician neglects to determine an underlying cause of symptoms 295 85%The physician documents treatment but not a diagnosis 326 93%There are documentation inconsistencies between physicians 298 85%Other (please specify) 29 8%

ACDIS benchmarking survey: Physician queries

Survey Says: Use CDI Best Practices to Query Physicians10

6. Which of the following methods of leaving a written query for a physician have you found to be the most effective?

Note: For each category, the left figure is the count of respondents selecting the option. The right figure is the percentage of total respondents selecting the option.

Least effective

Somewhat effective

Most effective

Leave a query in the patient’s medical record 21 6% 124 36% 202 58%E-mail the physician directly 125 53% 80 34% 29 12%Fax the physician office 123 48% 108 42% 26 10%Hand a query form to the physician 69 24% 96 33% 125 43%Hand a query form to the physician assistant 87 33% 87 33% 88 34%

7. Which of the following standard elements does your query form include (check all that apply)?

Patient name 335 97%Admission date and/or date of service 309 89%Health record number 304 88%Account number 296 85%Date the query was initiated 337 97%Name of staff member who initiated query 321 93%Name/contact information of the professional submitting the query 323 93%Relevant facts from the medical record, including dates when appropriate 337 97%The need for clarification 331 95%Open-ended questions 263 76%Dollar amount of potential change 5 1%ICD-9-CM codes/MS-DRG information 68 20%Facility name or logo 220 63%Other (please specify) 57 16%

8. Who was involved in developing your query forms (check all that apply)? Physician advisor 92 27%Coding staff members 188 55%Nursing staff members 79 23%Case management staff members 72 21%Legal department 46 13%Other (please specify) 213 62%

April 2009 11

9. How often do you review your query forms?

Quarterly 115 36%Biannually 28 9%Yearly 99 31%Once every two or three years 11 3%We do not review them 67 21%

10. Do you have a verbal query process and policy?

Yes 155 45%No 188 55%

11. If yes, how did you create this policy (check all that apply)?

Created it solely within our CDI department 60 35%With a task force, including participants from compliance, HIM, finance, case management, medical staff 50 29%Reviewed AHIMA’s policy and CMS guidance 92 54%Borrowed best practices from other CDI programs 43 25%Based it on guidance from consulting firm 61 36%Other (please specify) 33 19%

12. How do you document verbal queries (please check all that apply)?

On a note in the medical record 15 5%

In a central database/spreadsheet 125 41%

Within the case management/utilization review worksheet 63 21%

On a physician communication form 51 17%

We do not document verbal queries 36 12%

Other (please specify) 111 37%

13. Which of the following items do you track in regard to verbal queries (check all that apply)?

Query date 219 82%

Query time 84 32%

Name of CDI specialist 220 83%

Paraphrase of the question asked 192 72%

Name of the physician 234 88%

Paraphrase of the physician’s response 174 65%

Other (please specify) 62 23%

Survey Says: Use CDI Best Practices to Query Physicians12

14. Do you have an internal mechanism for tracking physician queries?

Yes 317 93%

No 25 7%

15. What elements does your query tracking form contain (check all that apply)?

Method of query (i.e., written or verbal) 197 60%

Name of physician 312 95%

Date of physician response 219 67%

Type of physician response 272 83%

Origin of inquiry (i.e., CDI specialist or coding staff member) 231 70%

Name of staff member performing query 271 83%

Description of follow-up if necessary 145 44%

Room number of patient 123 38%

Number of days followed 115 35%

Initial DRG 225 69%

Working DRG 235 72%

Other (please specify) 62 19%

16. Do you make your queries part of the patient’s permanent medical record?

Yes 96 28%No 248 72%

17. Which of the following physician query elements do you audit/monitor (check all that apply)?

Unnecessary queries 90 27%Leading queries 102 30%Rates of queries issued by CDI specialist 236 70%Rates of queries administered to individual physicians 212 63%Rates of queries administered to individual physician groups/departments 130 39%Financial effect of queries 239 71%Severity of illness/other effect of queries 189 56%Percentage of positive and negative query responses 264 79%Other (please specify) 48 14%

April 2009 13

18. What is your response rate to physician queries?

Under 40% 13 4%41%–50% 19 6%51%–60% 41 12%61%–70% 40 12%71%–80% 58 17%81%–90% 64 19%91%–95% 34 10%96%–100% 46 13%Other (please specify) 27 8%Total 342 100%

19. Do you track and report your query responses by:

Physician 279 85%Specialty 87 27%Hospital floor or department 29 9%Other (please specify) 51 16%

20. Does your compliance department independently audit your queries?

Yes 61 18%No 276 82%

04/09 SR2209

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