CMS allows physician queries, but with conditions

Hospitals transitioning to MS-DRGs and POA reporting are citing an increased incidence of physician queries by the HIM staff to clarify the clinical documentation used in code determination. This presents a potentially sticky situation, since CMS has traditionally not allowed — until recently — the inclusion of query forms in the medical record to support coding determination during an audit or a review by a Quality Improvement Organization (QIO).

In this latest policy clarification, CMS stated a query form would be considered acceptable "to the extent it provides clarification and is consistent with other medical record documentation." The agency's position is that a query form should not be leading, and it should not introduce new information not otherwise contained in the medical record.

"The Query Quagmire,", an article in the Jan. 7, 2008 issue of For the Record, provides additional clarification:

Careful phrasing is important for questions to the medical staff; they must not lead or prompt the physician to use specific terminology to increase the payment. For instance, an inappropriate question would be the following: 'Dr. X, if this patient had acute blood loss anemia, it would increase the hospital payment by $2,000. If the patient had this diagnosis, please document in the discharge summary.' This is a blatant incentive to document the diagnosis for the offered $2,000 carrot. Even a more subtle approach that says, 'Acute blood loss anemia is a CC [complication and comorbidity]; please document if correct,' can be considered too leading.

The query also shouldn’t introduce information that is not already documented in the chart or hasn’t already been considered by the physician. Consider the following example: 'Dr. X, this patient had a urinary tract infection [UTI] in the emergency department visit when I coded that case last week. If he is still taking antibiotics, could you please document the UTI?'

Additional tips from the article detail communications that are inappropriate to support code assignment and should not be considered a permanent part of the patient record. These include:

• E-mail, text messages and phone conversations between coders and clinicians.
• Face-to-face verbal communications that are not documented in a formal query form and signed by the clinician.

The author recommends that hospitals develop or use CMS-approved physician query forms, which can be found at the TMF Health Quality Institute’s Web site, or by following the instructions in an AHIMA practice brief, which can be purchased here.