Has the Time Come for Query Focus Groups?

No one relishes a coding query.

Mention a query to coding staff and you may get some eye rolls. Coders get anxiety when writing them, leadership wants less of them to keep the discharged not final billed (DNFB) down and revenue flowing, physicians get irritated by receiving them, and the list goes on and on. 

If you are new to the industry or have been coding in pro-fee or outpatient only, you may be wondering, why all the fuss about queries?  Coding queries are a necessary evil of sorts. They are primarily used in the inpatient setting for documentation clarification to aid in accurate code assignment, although some facilities have begun using coding queries similarly in the outpatient setting.  

Coders

Most coders have a love/hate relationship with queries. Writing an effective query is almost an art form, and a necessary task to garner a physician response. However, many coders dread writing queries for fear of backlash from the physician, who may feel their medical authority is being questioned, or from management, who need DNFB rates down and claims going out the door quickly. Some coders have a good record with queries, and some can tend to overuse them. 

Physicians

Many physicians have a strained relationship with queries and the coding staffers who send them. Often, again, a physician may feel that his or her medical expertise is being questioned and may become defensive, or they may just refuse to respond to queries in general. Why should physicians cooperate with queries and answer them, anyway? 

Management/Leadership

Coding management has the important responsibility of supporting and encouraging queries while simultaneously keeping a tight reign on unnecessary or ill-worded queries. Management can set the tone in this area: when to query, how to query, how to word a query, and appropriate query scenarios, for example. Management also can standardize many queries for certain typical scenarios, such as unspecified CHF, unspecified CKD, sepsis, and other ambiguous documentation.

Many facilities have created query focus groups that have gone on to create standard query templates to assist coders in appropriate query writing – and at the same time, minimize physician backlash. 

Clinical Documentation Improvement (CDI)

Clinical documentation specialists may add the most value to the query process. CDI folks are usually the most effective at queries, and they have a key role in the process. These specialists tend to have a stronger relationship with physicians, and the physicians don’t typically feel their medical expertise is being questioned, so they are much more likely to respond. 

Quality  

Most quality departments are adept at using queries and have a good gauge of when one would be appropriate. Quality departments can work with coding departments by providing pre-bill reviews and returning accounts to coding staff that would be appropriate for querying for documentation and/or condition clarification. This can be helpful, as the quality department is tasked with the responsibility of reporting hospital quality measure statistics.   

But really, why should we query? Most people, when they think of queries, usually think of coding as being the reason. However, depending on your job, you may view them as something else. For example, someone who works in quality will view a query as an opportunity to accurately capture the patient’s severity of illness, length of stay, or the potential impact on severity of illness and expected mortality, all of which impact the facility’s quality reporting.

A coder and coding manager will view a query as an opportunity to clarify diagnoses and procedures for correct coding, correct DRG assignment, and appropriate reimbursement.

What happens to a facility when physicians don’t respond to queries? It could impact justification of the patient’s length of stay. It could also mean an inability to report a CC/MCC condition, which could have an impact on reimbursement. It could also have an impact on the patient’s recorded severity of illness and expected mortality, thus impacting the DRG assignment and the facility’s quality measure reporting.

Why should the physician respond to a query? What’s in it for him or her? Queries are not just about coding and DRG assignment. As mentioned above, queries can clarify documentation about a patient’s severity of illness and expected mortality and other metrics, and also lower the risk of potential exclusion from Accountable Care Organizations (ACOs).

Ultimately, we all have to face it: There are documentation issues that are not going away anytime soon. These include chest pain, MI, CHF, SIRS/sepsis/bacteremia, pneumonia, CKD, respiratory failure, elevated troponins, and the list goes on. Queries are a necessary process that must be dealt with ethically and effectively.

Perhaps it’s time to turn over a new leaf and bury the hatchet in this New Year and make 2017 the year of cooperation with queries.