Improving ICD-10 Documentation by Querying Providers Query process is important to capture correct details from providers and update documentation appropriately for the ICD-10 system.
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As ICD-10 has finally become a reality, practices are required to give prime attention to accurate documentation. ICD-10 documentation is subjected to several challenges owing to the increased specificity of the classification system. For example, documentation of trimester is now required for pregnancy. The trimester should be counted from the first day of the last menstrual period. The number of weeks should be documented as well. A combination approach that involves EHR and medical transcription can facilitate intervention from health documentation specialists and thereby enhance the documentation quality. However, querying providers to clarify ambiguous documentation is quite important to clear the air on ICD-10 intricacies and create more comprehensive and timely documentation.
Accurate ICD-10 documentation must identify the conditions that require clinical evaluation, therapeutic treatment, further diagnostic studies, procedures or consultation, whether the patient’s length of stay was extended, or nursing care and/or monitoring was increased. A well-designed query process can capture relevant details from the providers regarding these matters to create quality documentation that will help eliminate reimbursement and compliance issues. There are two types of queries such as:
Retrospective – This type of query is performed either after discharge or pending claims submission in order to review information that is missing from the medical record.
Concurrent – This is an ongoing query process that involves screening of the provider’s documentation and querying the provider for clarification or additional information required while the patient is still in-house.
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Query Format Every query must include information that correctly identifies the patient and the encounter that led to the query. There would be a standard query format approved by the concerned organization and you should use such approved forms. The minimum details that should be included in a query are:
Patient name
Admission date (date of service)
Medical record number
Account number
Data query initiated
Name and contact information of the query initiator
A statement regarding the issue (clinical indicators from the medical chart or ambiguous/unsubstantiated information)
Important Guidelines for the Query Process You should keep in mind the following while querying providers:
The condition or diagnosis that is the source of the query should be established in the medical record
You should query all payer types instead of sticking to only those that have an impact on your reimbursement.
Your query should state the facts.
Your queries should not guide the provider to a specific diagnosis.
When you get the response to a query from the provider, you can document that in the progress note, discharge summary or on the query form as a part of the medical record.
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If there are addendums to the discharge summary or progress note, include the appropriate date as well as authentication.
You should also ensure that the individuals who perform the query process are educated and qualified along with the following strong competencies such as:
Familiar
with
healthcare
regulations
including
reimbursement
and
documentation requirements
Clinical knowledge along with training in pathophysiology
Ability to read as well as analyze all information within a patient’s record
Communicate well with providers and other clinicians
Demonstrated skills in clinical terminology, coding and classification systems
Ability to apply official guidelines and other relevant conventions to documentation
When to Query a Provider The queries are considered appropriate at a time when the patient’s records are:
Not Clear – The diagnosis is listed on the record without statement of cause or suspected cause. The procedures are not clearly documented as recommended for ICD-10-PCS.
Not Complete – Data entered into the patient record don’t relate to clinical indicators or diagnostic tests (for example, missing test results, progress notes or discharge summary).
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Inconsistent – The information that you have documented is conflicting or not substantiated. The documentation in the progress notes may often conflict with information in the discharge summary or documentation of another provider.
Incorrect – This refers to the documentation of an unspecified diagnosis while the clinical reports suggest a need for more specific diagnosis.
You should understand not only when to query the provider, but also when not to query providers. The providers often make clinical diagnosis that may seem to be inconsistent with test results. The queries should not question such kind of clinical judgments, but clarify documentation that fails to meet any of the criteria mentioned earlier.
A well-designed query process serves as an effective communication tool to improve data integrity. Such a process will help practices to continually update documentation for ICD-10 success.
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800-670-2809