Physician Queries and Their Impact

on Monday, 04 March 2013. All News Items | Documentation | Coding

 

In this day and time, a physician query is nothing new to the ever changing healthcare environment. As true as that may be, coders are still hesitant to query. One of the main reasons I often hear is that it would not affect the DRG. Another reason would be time. A physician query takes a little time to create and follow. This can cut into a coder’s production rate even in facilities with a strong CDI (Clinical Documentation Improvement) program. Another reason would be lack of experience and/or lack of clinical knowledge. Coders have never before had to be as clinical as they are now required to be. It’s very important for coders to gain as much knowledge in Pathophysiology as possible. This will aid them in recognizing when a query is needed and when it’s appropriate.

Coding as we all know is in itself a very skilled process requiring careful review and analysis of the medical record. There is an increased demand and responsibility on coders to ensure data quality. Coders are the last to thoroughly analyze the medical record. This is the last chance to catch any potential need for additional documentation before completing a coded claim for the billing department to process on to the payer.

It is essential to ensure codes provided on claims submissions are accurate, complete and supported by medical records documentation.

The clinical data obtained on claim submissions play a very important and increasing role driving future health care regulation, compliance and reimbursement.

The following examples are situations that may warrant a physician query.

  1. There are clinical indicators of a diagnosis without documentation of the condition.
  2. Clinical evidence of a higher degree of severity or specificity.
  3. A cause-and-effect relationship between two conditions or organism.
  4. Lack of present on admission (POA) indicator status.
  5. Admitted with symptoms without an underlying cause.
  6. Only the treatment is documented (without a definitive diagnosis).

A physician’s clinical judgment should never be questioned. A query may be sent when the physician’s documentation is not clear, precise, legible, complete or consistent.

A physician query is a communication tool meant to clarify documentation in the medical record and is to assure coding accuracy. Accurate coding results in:

  • Quality data
  • Proper reimbursement
  • Accurate reflection of “Severity of Illness” (SOI)

Refer to the following example:

A 65 year old white female is admitted with muscle weakness, painful burning and tingling sensation of the feet and lower extremities. Patient states she has been having trouble staying balanced while walking. Glucose level on admission was 425. This fluctuated throughout admission but remained elevated.

Previous history: Diabetes Mellitus Type 2, CAD, HTN, CHF, COPD, Neuropathy

Physical exam shows edema of the lower extremities with venous insufficiency. A 3cm purulent sore covered the left ankle. Lab came back positive for MRSA.

Patient placed on sliding scale insulin and diabetic diet. Wound treated with sharp debridement and IV Vancomycin.

Impression: Diabetic Neuropathy, CAD, HTN, CHF and COPD.

Codes w/o Query

Potential Codes with Query

Potential Codes with Query and DRG Change

Diabetic Neuropathy 250.00 & 357.2

Diabetic Neuropathy Uncon. 250.62 & 357.2

Diabetic Neuropathy Uncon. 250.62 & 357.2

CAD 414.01

Cellulitis 682.6

Cellulitis 682.6

HTN 401.9

Chronic Ulcer Ankle 707.13

Chronic Ulcer Ankle 707.13

CHF 428.0

MRSA 041.12

MRSA 041.12

COPD 496

CAD 414.01

CAD 414.01

Venous Insuff 459.81

Venous Insuff 459.81

Venous Insuff 459.81

 

HTN 401.9

HTN 401.9

 

CHF 428.0

CHF 428.0

 

COPD 496

COPD 496

 

 

 

Non-Excis. Deb. 86.28

Non-Excis. Deb. 86.28

Excisional Deb. 86.22

 

 

 

DRG - #074

Cranial and Peripheral Nerve Disorder without MCC

DRG - #074

Cranial and Peripheral Nerve Disorder without MCC

DRG - #041

Peripheral/Cranial Nerve and Other Nervous System Procedures with CC

Weight - 0.8837

Weight - 0.8837

Weight - 2.1330

 

As you can see from the middle column, a physician query can make a difference in severity of illness whether it affects the DRG or not. From the brief information given in the above note, it appears that the patient had an infected ulceration. A physician query could clarify uncontrolled diabetes in addition to cellulitis, MRSA and the ankle ulceration. The codes for cellulitis and the ankle ulceration would both be a CC. An additional query could clarify whether the procedure was an excisional or non-excisional debridement which in this case would affect the DRG.

The question you may want to ask is “Which set of codes is more reflective of the resources used and treatment given to patient”? The data in the middle column may not affect the current DRG but possibly could in the future when CMS is reviewing Med PAR (Medicare Provider Analysis and Review) file to determine your facilities potential base rate.

References:

Journal of AHIMA – February 2013, Guidelines for Achieving a Compliant Query Practice.

AHIMA "Managing an Effective Query Process" Journal of AHIMA 79, no.10 (October 2008): 83-88.

HCPro / Just Coding – Guidance and Tact Key to Compliant, Effective Physician Queries. May 10, 2011 Article

Article by Marsha Manning

Marsha Manning RHIT, CCS, AHIMA Approved ICD-10-CM/PCS Trainer, is an Inpatient Coding Consultant at Medical Management Plus, Inc. Marsha has over 23 years experience in the coding profession and has held various positions such as DRG coordinator, Coding Supervisor and HIM Supervisor. In her current position, Marsha reviews records and assists clients with coding accuracy, compliance, education and Case Mix Index (CMI) as they relate to specific entities concerning Medicare. You may contact Marsha at This email address is being protected from spambots. You need JavaScript enabled to view it..

 

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