developing a query process for the physician practice or ... · 465.9 uri (upper respiratory...

© Copyright 2008 American Health Information Management Association. All rights reserved.

Developing a Query Process for the Physician Practice or

Home Health Agency

Disclaimer

AHIMA • http://campus.ahima.org

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The American Health Information Management Association makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. AHIMA has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this audio seminar, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this program. AHIMA makes no guarantee that the use of this program will prevent differences of opinion or disputes with Medicare or other third party payers as to the amount that will be paid to providers of service.

How to earn one (1) CEU for participation

To earn one (1) continuing education unit, each participant must do the following: Step 1: Listen to the seminar, via Webcast link or audio CD. Step 2: Complete the assessment quiz contained in this resource book.

Use the included answer key. Do not return the quiz to AHIMA. Save it for your records.

Step 3: EACH LISTENER must visit

http://campus.ahima.org/audio/fastfactsresources.html and complete the sign-in form and the seminar evaluation.

Step 4: After you complete the evaluation, you will receive your CE certificate which

you should print for your records. The certificate must be retained by each participant as a record of their participation, along with a copy of their completed quiz.

Faculty


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Shelley C. Safian, CCS-P, CPC-H, CHA

Shelley C. Safian, Chair of the Allied Health Department at Herzing College, is also the Senior Assistant Professor for the Medical Billing and Insurance Coding program. She is currently teaching coding and medical office administration at both Herzing College – Winter Park (Orlando), Florida as well as Herzing College Online.

Safian is a Certified Coding Specialist-Physician-based from the American Health Information Management Association (AHIMA) and a Certified Professional Coder- Hospital from the American Academy of Professional Coders (AAPC). She also holds a National Certified Insurance Coding Specialist (NCICS) designation, as well as that of Certified HIPAA Administrator (CHA).

Safian completed her Graduate Certificate in Health Care Management in June 2005 at Keller Graduate School of Management. The University of Phoenix awarded her Master of Arts/Organizational Management degree in 2002.

The Florida Association of Post-secondary Schools and Colleges (FAPSC) named Safian Faculty Member of the Year 2006–2007. Herzing College, Winter Park honored Safian by naming her 2007 Teacher of the Year, and she was awarded the Faculty Scholarship Award—First Runner Up for the Herzing College System for 2006.

Safian is a volunteer AHIMA Mentor, working with health information management students from all across the country, and sits on the AHIMA Classification Practice Council. She attends local chapter meetings of the Central Florida Health Information Management Association (CFHIMA) whenever her schedule permits, and encourages her students to join her at the Florida Health Information Management Association (FHIMA) Annual Convention every year.

McGraw-Hill Higher Education published Insurance Coding & Electronic Claims for the Medical Office by Safian in July, 2005. Her second, third, and fourth books, The Complete Procedure Coding Book, The Complete Diagnosis Coding Book, and You Code It! A Case Studies Workbook were published simultaneously in February, 2008.

Table of Contents


Disclaimer ..................................................................................................................... i How to earn one (1) CEU for participation ......................................................................... i Faculty ......................................................................................................................... ii What is a query? ............................................................................................................ 1 Why should you query? ............................................................................................... 1-2 Reasons to query ........................................................................................................ 3-6 How to create a query ................................................................................................ 6-10 Submitting the query ..................................................................................................... 11 When to query .............................................................................................................. 12 Getting buy-in .......................................................................................................... 12-13 Queries and clinial documentation ............................................................................. 13-14 Resource/Reference List ................................................................................................ 15 AHIMA Audio Seminars .................................................................................................. 15 About assessment quiz .................................................................................................. 16 Thank you for attending (with link for evaluation survey) ................................................. 16 Appendix .................................................................................................................. 17 Web Resource List Sample Physician Query Form Assessment Quiz CE Certificate and Sign-in Instructions Quiz Answer Key

Developing a Query Process…

AHIMA • http://campus.ahima.org 1

Notes/Comments

What is a Query?

Query = To Ask

• An official query is defined as a question presented to a health care provider in an effort to gain additional documentation so the HIM professional can more accurately assign a code or codes.

1

Why should you Query?

“A joint effort between the health care provider and the coding professional is essential to achieve compete and accurate documentation, code assignment, and reporting of diagnoses and procedures.”

ICD-9-CM Official Guidelines for Coding & Reporting

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Notes/Comments


• Centers for Medicare and Medicaid Services supports the use of query forms as a supplement to the health care record.

“Use of the physician query form is permissible to the extent it provides clarification and is consistent with other medical record documentation.”

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• Office of the Inspector General (OIG) warns HIM professionals against interpreting too far without substantial documentation, identifying assumption coding as a forbidden practice. The OIG defines assumption coding as…

“Assuming (and coding) from the clinical evidence on the patient’s record that the patient has certain diagnoses in the absence of the physician’s explicit documentation of diagnosis.”

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Notes/Comments

Reasons to Query?

• When the clinical documentation is

•Ambiguous•Inconsistent•Missing specificity

5

Reasons to Query?

Ambiguous• Information is not clear

• Diagnosis with no mention in record of signs, symptoms, test results, etc.

• Documentation is illegible• Handwritten notation that cannot be read

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Notes/Comments

Reasons to Query?

AmbiguousExample:

Preprinted encounter form (Superbill) shows check marks for:465.9 URI (upper respiratory infection)81000 Urinalysis, by dip stick

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Reasons to Query?

Inconsistent•Information is not in agreementExample:

• Attending physician documents diagnosis of strep throat

• Pathology report identifies esophagus tuberculosis

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Notes/Comments

Reasons to Query?

Missing•Information is not completeExample:

• Physician documents diagnosis of malignant neoplasm of the breast

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Reasons to Query?

Missing• Location within the breast of neoplasm (nipple; central; lower-outer quadrant; etc.)

• Estrogen receptor

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Notes/Comments

Reasons to Query?

•Missing• You must query the physician to have him

or her document the specific location of the neoplasm

• 174.9 Malignant neoplasm of breast (female), unspecified should be an absolute LAST choice!

• Unspecified codes are most likely to be denied or pulled for additional information requests (delaying payments)

11

How to Create a Query

Always include:• Patient name• Date of service• Health record #/Account #• Date query initiated• Name and contact information for individual

initiating the query...plus...

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Notes/Comments


...plus…

•Background information (clinical data from the medical record as applicable)

•The Question!

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Formatting the Question• Assure the question does not sound as if it

questions the physician’s judgment

Example

“Dr. Jones, the chart shows the patient’s B/P has been 175/110 the last three visits. Shouldn’t you document a diagnosis of hypertension?”

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Notes/Comments

How to Create a Query?

Formatting the Question• Assure the question is not leading

Example

“Dr. Jones, the patient was diagnosed with anemia and received a transfusion. Please document idiopathic anemia.”

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Formatting the Question• Open Ended Question

Example

“Dr. Jones, the patient was diagnosed with anemia and received a transfusion. Please document the cause of the anemia.”

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Notes/Comments


Formatting the Question• Multiple choice questions

Example

“Dr. Jones, the patient was diagnosed with a closed fractured sacrum/coccyx. Please document:• With complete cauda equina lesion• With other cauda equina injury• With other spinal cord injury• Other ___________________________• Unable to determine

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Formatting the Question• Yes/No Question

Example

“Dr. Jones, the pathology report identifies the patient may have multiple myeloma. Do you agree? Yes or No.”

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Notes/Comments


Formatting the Question• Verbal Question

Concern

• No documentation to support query to prove it was not leading physician to upcode

• Physician response may never be verbal

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Formatting the Question• No matter what… make certain the question cannot be interpreted to be leading the physician to write a diagnosis influenced by reimbursement level or coverage.

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Notes/Comments

Submitting the Query

• Establish office policy

• Official office query form can be created

• Should NOT be on sticky note or anything else that is easily lost or misplaced

• Determine if query form is to become part of the official patient record or not

• Establish preferred response timeframe

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Submitting the Query

Methods of transmittal• Facility-approved form (paper)

• Clipped to front of patient chart• On desk/in box/special location

• Secured electronic system• Internal e-mail or Intranet

• Fax machine• Use with caution

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Notes/Comments

When to Query

• Concurrent• Home care, SNF, LTC

• Retrospective• After patient has left, before claim is submitted

• Post-Bill• After rejection or denial of claim• After request for more information from payer• After an audit

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Getting the Buy-In

Educating clinicians on the value of queries• We need to know some things that are in

their heads and were just not written down

• Physicians do not learn to document for coding, so they do not know what specifics we need

• More specific documentation = more specific codes

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Notes/Comments

Getting the Buy-In

Educating clinicians on the value of queries• More specific codes =

• Fewer denied claims • Fewer claims pulled for determination• Optimal reimbursement rates• Improved quality of PQRI reporting• Higher Physician Quality Report Cards• Better resource utilization analyses

25

Queries and Clinical Documentation

“The importance of consistent, complete documentation in the medical records cannot be overemphasized. Without such documentation accurate coding cannot be achieved.”

ICD-9-CM Official Guidelines for Coding & Reporting

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Notes/Comments


Queries help to assure that the clinical documentation can be interpreted in a manner that will gain accurate, appropriate reimbursement for the services provided to each and every patient.

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Quality Documentation

Quality Coding

Optimal Reimbursement

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Notes/Comments

Resource/Reference List

• ICD-9-CM Official Guidelines for Coding and Reporting (10/1/2007)www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm#guidelines

• Federal Register/Physician Querywww.gpoaccess.gov/fr/index.html

• Office of Inspector Generalwww.oig.hhs.gov

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Visit our Web site http://campus.AHIMA.orgfor updated information on the current seminar schedule. While online, you can also register for live seminars or order CDs and Webcasts of past seminars.

© 2008 American Health Information Management Association



Notes/Comments

Assessment

To access the assessment quiz that follows this seminar, download the seminar’s resource book at

http://campus.ahima.org/audio/fastfactsresources.html

Your sign-in form and certificate of completion are also found in the resource book.

Thank you for attending!

Please visit the AHIMA Audio Seminars Web site to complete your evaluation form online at:

http://campus.ahima.org/audio/fastfactsresources.html

NOTE: This slide is referring to THIS resource book.

To take the assessment quiz, turn to the end of this book.

Appendix


Web Resource List Sample Physician Query Form Assessment Quiz CE Certificate and Sign-in Instructions Quiz Answer Key

Appendix


Web Resource List

ICD-9-CM Official Guidelines for Coding and Reporting (10/1/2007) www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm#guidelines

Federal Register/Physician Query www.gpoaccess.gov/fr/index.html

Office of Inspector General www.oig.hhs.gov

SAMPLEPHYSICIANQUERYFORMDate:___Today___________PATIENTNAME:___JoeP.Patient______________________________________________HEALTHRECORD#/ACCOUNT#:___JPP1099____________________________________DATEOFSERVICE:__8/08/08_________DearDr.__Ortho_____:Thisqueryisbeinginitiatedbecausethecoderneedssomeadditionalinformationregardingtheabovepatientduringtheabove‐identifiedencounter.Thepatientwasdiagnosedwithafractureofthelefthumerus.Pleasedocumentinthischartthefollowingspecificstoenableustocodemoreaccurately.Thispatient’sfractureis:[]Open[]Closed[]Unabletodetermine[]Other

Theportionofthehumerusthatwasfracturedis:

• Upperend

o Proximalend/shoulder

o Surgicalneck

o Anatomicalneck

o Greatertuberosity

• Shaft

o Shaft

o Lessertuberosity

• Lowerend

o Supracondylar

o Lateralcondyle(externalcondyle)

o Medicalcondyle(internalepicondyle)

o Articularprocess/lowerepiphysis

• Other:____________________________________

• Unabletodetermine

Thankyouverymuchforyourassistance.

CONTACTOFINDIVIDUALSUBMITTINGQUERY:

NAME:__________________________________PHONE#:_______________________________E‐MAIL:_________________________________

Assessment Quiz – Developing a Query Process… Phys. Practice or Home Health

AHIMA • http://campus.ahima.org ANSWERS to this quiz are found on the last page of the seminar resource book, Practical Tools for Seminar Learning.

To earn continuing education credit of one (1) AHIMA CEU, Fast Facts Audio Seminar listeners must also complete this 10-question quiz. This CE credit is for attending the audio seminar AND completing this quiz. Please keep a copy of the completed quiz with your CE certificate. Do not send a copy to AHIMA.

1. Legally, when faced with missing details, the

coder should: a. Figure it out on his or her own b. Query the attending physician c. Ask the supervisor d. Consult the Merck Manual

2. If documentation is ambiguous, it means that it

is: a. Missing details b. In disagreement with other files c. Outside of the physician’s scope of practice d. Unclear

3. The report states that a chest x-ray was done,

two views, without further detail. The coder should: a. Assume frontal and lateral b. Check the patient’s record for previous

radiology reports c. Query the radiologist or attending physician d. Choose the chest x-ray code that reimburses

at the highest rate 4. Foam wound cover dressings are coded based on

the size of the pad and whether or not the dressing has an adhesive border. The notes, from the health care professional who applied the dressing, do not specify either. The coder should: a. Code for the most common size used b. Query the health care professional who

performed the service c. Send the bill to the patient d. Code for the largest size

5. True or false? It is permissible to write a query to

a physician, in the same office, on a sticky note. True False

6. “Dr. Smith, Please document in the patient’s

chart that her hemorrhoids were prolapsed.” This query is: a. Leading b. Legal c. Helpful d. Efficient

7. Dr. Jones requested that queries be sent to him

using his son’s e-mail address: [email protected]. This method is: a. Not secure and should not be sent this way b. OK, as long as this is the physician’s

preference c. HIPAA-compliant because it is password

protected d. All of the above

8. Queries should not be made:

a. Concurrently b. Retrospectively c. Orally d. Post-Billing

9. More specific documentation enables more

specific codes that does not lead to: a. Fewer denied claims b. Greater liability c. Fewer claims pulled for additional information d. Optimal reimbursement payment rates

10. Querying for clarification in an effort to code

more accurately is supported by: a. OIG b. CMS c. ICD-9-CM Official Guidelines d. All of the above

Do not send a copy of completed quizzes to AHIMA. Please keep them with your CE certificate, for your records.

Be sure to sign-in and complete your evaluation form, to receive your certificate, at http://campus.ahima.org/audio/fastfactsresources.html.

To receive your

CE Certificate

visit http://campus.ahima.org/audio/fastfactsresources.html

click on the link to

“Sign In and Complete Online Evaluation” listed for this seminar.

You will be automatically linked to the

CE certificate for this seminar after completing the evaluation.

Each participant expecting to receive continuing education credit must complete the online evaluation and sign-in information,

in order to view and print the CE certificate.


Quiz Answer Key Fast Facts Audio Seminar: Developing a Query Process for the Physician Practice or Home Health Agency 1: b; 2:d; 3: c; 4: b; 5: false; 6: a; 7: a; 8: c; 9: b; 10: d Do not send a copy of your completed Fast Facts Audio Seminar quiz to AHIMA. Please keep it with your CE certificate, for your records.

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