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Successful Physician Queries

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Medicare Severity DRGs (MS-DRGs) have put a far greater onus on accurate and concurrent clinical documentation that pinpoints severity of illness and cost of care. These new MS-DRGs will require coding professionals to not only code for severity, but also undertake a higher level of clinical knowledge and/or work in tandem with a clinical documentation specialist (CDS).

Rather than pick a single DRG code, coding professionals must now specify a diagnosis and indicate severity. For example, traditionally, congestive heart failure would have been coded in an unspecified way and all cases lumped under one code. Now, coding professionals can indicate whether the heart failure was an acute or chronic case, with an acute getting higher severity or MCC, and note comorbid conditions or secondary diagnoses, such as respiratory conditions or regular malnutrition (CC) or severe malnutrition (MCC)--chronic conditions that would warrant more hospital resources.

This is where concurrent documentation review and physician queries come into play. Concurrent documentation investigation--reviewing and re-reviewing the record while the patient is still in the hospital--promotes opportunities for real-time process improvement and facilitates face-to face interaction with physicians and most importantly, avoids retrospectively asking the physician to recall what happened after the fact.

While some coding professionals might feel uncomfortable about mixing the goals of coding accuracy with improved reimbursement, both are now achievable under the new MS-DRG system. The key is issuing physician queries that are judiciously used as a tool to improve the accuracy of code assignment and the quality of physician documentation.

What Is an Effective, Compliant Physician Query?
Physician queries are meant to improve the accuracy of coding by actively involving the staff physician in the clarification and full completion of any documentation. A physician query is the process recommended by the American Hospital Association (AHA) Coding Clinic guidelines when specificity or clarification regarding a specific diagnosis being treated is not clearly stated in the medical record (Coding Clinic 1Q 1993).

Per the Journal of AHIMA, Practice Brief, October 2001, a valid query will present specific fact(s) derived from the medical record and identify why clarification is needed. It will present the scenario and state a question that asks the physician to make a clinical interpretation, clarification or determination of a diagnosis or condition based on treatment, evaluation, monitoring and/or services provided.

Currently, many queries are too generic and don't give the physician an effective way to return an answer that leads to specificity. For example, a general inquiry might read, "Based on nurses notes, please render an opinion or diagnosis of heel decubitus on this patient." For a physician, this is a frustrating scenario, because they feel the documentation already addresses patient care. Physicians respond more successfully to clinically specific queries.

The following query would be a more successful, yet valid and compliant way to determine a diagnosis that leads to more accurate coding under the new MS-DRG system.

"Based on documentation that notes worsening CHF, increased dyspnea, JVD, bilat rales, treatment with bumex, were you treating this patient for acute systolic or diastolic heart failure? If you agree, please document in the progress notes and discharge summary."

This phrasing hones in on asking for a more specific diagnosis and one that would be reimbursable as a secondary diagnosis (MCC) under new MS-DRGs.

Now, let's be clear, this more clinically accurate query should be phrased to allow the physician to specify the correct diagnosis, but it should not indicate the financial impact of the response to the query, as stated by AHIMA Reference: Practice Brief: "Developing a Physician Query Process," CMS October 2001.The physician query should not lead the physician to provide a particular response that is not supported by the facts; doing so could result in allegations of inappropriate upcoding.

Are your physician queries valid and non-leading? If so, they must do the following:

·        Use specific clinical documentation;

·        Be clear and concise;

·        Contain precise language;

·        Present fact(s) from the medical record;

·        Query based on treatment, evaluation, monitoring and services to allow the physician to make a clinical interpretation of a given diagnosis or condition; and

·        Allow physicians to document specific diagnoses.

New MS-DRGs Require Teamwork
Any clinical documentation program should support a compliant and effective physician query process that allows documentation deficiencies to be corrected while the patient is still in-house, positively influences patient care, promotes clinically credible queries and supports collaboration between physicians, documentation specialists and coding professionals. Working as a team, those charged with clinical documentation can identify opportunities resulting in appropriate severity coding to ensure complete, quality documentation, maximum reimbursement and severity reporting outcomes.

Melinda (Mel) Tully, is senior vice president, clinical services, J.A. Thomas and Associates. Scott Withrow is a compliance attorney with Scott C. Withrow, Esq. Compliance Attorney. You can contact the authors at Mel.Tully@JATHOMAS.COM or swithrow@wmolaw.com.


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Interestingly your so-called valid and compliant example is exactly the opposite. It is leading the physician to only one possible diagnosis, acute (systolic or diastolic) CHF, and is therefore NOT compliant or valid in any way, shape or form. This is the kind of dribble CDS' are learning and is creating friction between experienced coders who are trained to follow coding guidelines to the letter and nurses trying to be coders.

Ann May 18, 2010



Can you go a little further and advise coders on how to word a really specific query without it being interpreted as "leading" by CMS? This is a concern for many of us. Thanks.

Mary February 27, 2008



They were released effective 10/1/08. The following CHF codes are considered MCC's under MS-DRGs.
428.21 Acute systolic heart failure
428.23 Acute on chronic systolic heart failure
428.31 Acute diastolic heart failure
428.33 Acute on chronic diastolic heart failure
428.41 Acute systolic and diastolic heart failure
428.43 Acute on chronic systolic and diastolic heart failure, unspecified


Arlene Baril,  Executive Vice President,  PHNSFebruary 27, 2008
Dallas, TX



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