Compliant Queries that Led to Opening a Can of Worms

Well, it appears I opened a real can of worms last week when I mentioned a DRG downgrade audit finding received by a hospital for which the auditor noted that the query was leading. Two Monitor Mondays listeners asked two great questions.

First, Joe asked if there was a law or regulation that prohibits leading queries – and although you could not see it, healthcare attorneys David Glaser and Knicole Emanuel both noted in our internal chat that no such law or regulation exists.

I then had an online discussion with Dr. Erica Remer, and she in turn added that some of her clinical documentation integrity (CDI) colleagues agree that there is no such law. But that does not mean you have carte blanche to produce leading queries. Dr. Remer addressed this on Talk-Ten-Tuesdays (you can listen here) and with an article on ICD10monitor, and the American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Specialists (ACDIS) have released their guideline on compliant queries.

Who knew that healthcare billing and coding could be so complex? And to address David Glaser’s other chat comment, worms used as bait for fishing used to be sold in cans. When the fisherman opened the can, the worms would start wiggling and escape from the can. That led to the fisherman scrambling to catch them all.

Moving on, last week First Coast Service Options (FCSO), the Medicare Administrative Contractor (MAC) that serves Florida, issued a notice that they are seeing an increasing number of claims for anesthesia services provided to patients who were receiving epidural injections or facet joint injections.  

Their medical directors feel that anesthesia is not needed for these procedures, and as they said, if the patient has “needle phobia,” an oral anxiolytic should suffice. Is FCSO correct? Well, I admit that I have not done a literature search on the topic, but it seems that if patients managed to receive their injections without the services of an anesthesiologist in past years, why would it be necessary now? Was there a change in the injection technique that now warrants having an anesthesiologist? Is there new data on the risk of injections performed without anesthesia? I recall some of my first colonoscopies, and way back then, the gastroenterologist not only did the scoping, but they also supervised the nurse providing IV sedation. Now, it is routine to have an anesthesiologist. It certainly makes the procedure more comfortable for the patient, and the gastroenterologist can perform more procedures if they do not need to monitor the patient. The same argument could be made for cataract extraction. What role does patient comfort and efficiency play in deciding if a service is necessary? That’s a question I won’t touch.

Finally, UnitedHealthcare (UHC) released their new policy on observation services. But the old policy is really no different than the new policy. Once again, they say that observation is time-limited…but then the policy goes on to say that at that point, their medical director will determine if the patient warrants “an inpatient level of care.” How infuriating. “Inpatient” is not a level of care. The care provided to inpatients is the same as that provided to observation patients. “Inpatient” is a status, and it is appropriate for the patient who hits the end of the time allotted for observation but still requires ongoing hospital care. Now, if they want to say that the ICU level of care is not appropriate or telemetry is not appropriate, or even that hospital care is not appropriate, that is perfectly reasonable. But playing these games about inpatient and observation really must stop.

Programming note: Listen to Dr. Ronald Hirsch live as he makes his Monday Rounds on Monitor Mondays, 10 a.m. EST and sponsored by R1-RCM.


Ronald Hirsch, MD, FACP, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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