Clinical Documentation Matters

Note:  This procedure is provided as a sample procedure only.  Every organization must create policies and procedures specific to their organization, staff, and processes.

Purpose
To provide a standardized policy regarding querying of physician staff regarding documentation clarification for inpatients at the ABC Hospital which meets corporate compliance guidelines.

Scope
This policy applies to all ABC Hospital inpatients.

Responsibility
It is the responsibility of all Clinical Documentation Specialists (CDSs), Health Information Management, and Medical Staff to implement this policy.  It is the responsibility of the chief of service, Director of Case Management, and Director of Health Information Management to assure compliance to this policy.

The physician will be queried when an opportunity to improve the quality of documentation in the inpatient record is noted; queries may be made concurrently by CDSs or retrospectively by Health Information Management (HIM) in-patient coders or auditing staff.  Queries should be supported by clinical evidence in the patient’s record.  A query is never to be generated to misrepresent a patient’s diagnosis or condition.    

Concurrent queries – CDSs will query the patient’s MD if opportunities to improve documentation are noted during concurrent review of the patient’s record.  Queries will be written on the facility sticky notes or may be made verbally if the MD is on the patient care unit.

Physicians will be queried by CDSs for:

1. specificity in documentation
2. evaluation of lab data/radiology and other reports such as pathology as to the significance of any abnormalities or findings (and the name of the suspected/treated condition)
3. agreement and documentation of diagnoses documented by other members of the health care team [i.e., Nutrition, Substance abuse team (if not completed by MD member of team), Wound Care Team]
4. co-signature of NP and PA notes to be used for APR-DRG assignment and coding
5. differential diagnoses ruled in/out by discharge
6. conditions/procedure names which do not use approved hospital abbreviations
7. clarification if there are conflicts of diagnoses between consultant and the attending physician

Physicians (attending or resident) shall review and respond to queries within 24 hours whenever possible

1. If the MD agrees with the query, he/she is to document the applicable condition/procedure the next time they document in the progress notes.
2. If the MD does not agree with the query (i.e. there is no clinical significance for an abnormal lab test), they are to check off on the sticky note that they `disagree with the query’.

Retrospective queries – HIM coders will query the patient’s MD if opportunities to improve documentation are noted during retrospective review of the patient’s record. Queries of the attending physician after discharge should be made only when there is sufficient supporting documentation within the body of the medical record to warrant a query.  Questions about documentation in the record may arise during the coding process or as a result of a special audit.

1. The physician will be queried in the following situations:
2. documentation is inconsistent and/or ambiguous, unclear, incomplete, or unspecified or general in nature [AHIMA Standards of Ethical Coding and Compliance Guidance for Third Party Billing Companies, 1999]
3. principal diagnosis (reason for admission, after study) is not clearly identified
4. significant case manager queries not answered prior to discharge (e.g., those which would impact severity level)
5. abnormal diagnostic test results indicate the possible addition of a secondary diagnosis or increased specificity of an already documented condition
6. lack of clarity as to whether a condition has been ruled out
7. patient is receiving treatment for a condition that has not been documented
8. significance of abnormal operative/procedural/pathologic findings are not documented
9. pre-determined and agreed upon (with medical staff) clinical criteria are met
10. agreement and documentation of diagnoses documented by other members of the health care team [i.e., Nutrition, Substance abuse team (if not completed by MD member of team), Wound Care Team]

Query format

The physician query form will be used for all queries, including patient identification, reason for query, directions as to how to provide the requested documentation clarification, and contact information of the person executing the query.  If there are multiple questions for one case, the physician is to be alerted that there is more than one query requiring a response

1. In completing the reason for query on the physician query form, the coder will use open-ended questions and allow the physician to render and document his/her clinical interpretation of the diagnosis, condition, procedure, etc. based on the facts of the case.  Closed-ended `yes/no’ or `leading‘ questions will be avoided.
2. Exceptions to the open ended query, when it is appropriate to query for a specific diagnosis include the following:
   1. positive lab or radiology findings clinically supporting the diagnosis [Coding Clinic, 2nd quarter 1998]]
   2. medication is prescribed that supports the specific diagnosis [Coding Clinic, 1st quarter 1993 and 2nd quarter 1998]
3. Physicians (attending or resident) are to respond to retrospective queries within 5 business days (same day for special audits).
4. If they agree with the query, they are to document on a late entry documentation note form (see attached).  All entries must be signed and dated for the date the current entry is made.
5. If they disagree with the query, they are to indicate their reasons on the physician query form and return the form to HIM.
6. The late entry documentation note form shall be documented by the physician and, if applicable scanned into the hospital’s imaging system, if the physician documents additional information