ICD-10: Pitfalls of Noncompliant Queries

Noncompliant queries can be overt or subtle.

The underlying hallmark of clinical documentation integrity (CDI) programs is the query process utilized to clarify documentation from a diagnosis perspective.

Much emphasis is placed upon ensuring the issuing of a compliant query by the clinical documentation integrity specialists, reinforced by the American Health Information Management Association (AHIMA) Guidelines for Achieving a Compliant Query Practice Brief (2016 Update) (AHIMA Practice Brief).

CDI leadership at most healthcare facilities take painstaking efforts at ensuring compliant queries through the auditing process, as well as educating and reeducating staff on the constructs of compliant queries. The first paragraph of the AHIMA Practice Brief drives the tone and spirit of compliant queries with the following:

• In court, an attorney can’t “lead” a witness into a statement. In hospitals, coders and clinical documentation specialists can’t “lead” healthcare providers with queries. Therefore, appropriate etiquette must be followed when querying providers for additional health record information.

Despite overemphasis upon compliant queries, I am still observing in my own CDI practice existence of noncompliant queries in some form or fashion. Noncompliant queries can be overt or subtle, depending upon how the query is structured and worded; on face value, a query may appear to meet the definition of and be characterized as compliant, yet when you drill down further with respect to the clinical facts and information available in the chart, the query can suddenly appear to be noncompliant in nature.

Compliant Querying: Reality vs. Face Value
The practice brief outlines in detail the format and mechanics of compliant queries, providing excellent examples. What do I mean when referring to “reality” versus “face value?” “Reality” implies that CDI specialists follow the query practice brief guidelines in constructing their queries, providing relevant clinical indicators in the body of each and providing multiple responses, including “unable to determine” and/or “other.”

Often overlooked despite being critically important is the clinical picture, patient acuity, and severity, which often further support the diagnosis in question. A perfect example is a query for sepsis: the patient workup and treatment may support a diagnosis of sepsis with elevated WBC, lactic acid levels, bands, temperature, SIRs criteria, etc. However, when you take the time to read the chronological description of the history of present illness (H&P), constitutional portion of the physical exam, and clinical impression, a query for sepsis can appear on face value to be inappropriate and not clinically justified. Merely asking a physician to document a diagnosis through the query process, using clinical indicators without an accurate and complete picture of a patient with the diagnosis of record, constitutes a noncompliant query, in my mind.

We are all too familiar with these types of queries:

• A 72-year-old patient presents to the emergency department with documented altered mental status, elevated white blood cell count, and elevated temperature. Blood cultures are ordered, and the patient is receiving appropriate antibiotics. Constitutional physical exam states that the patient is alert and oriented, resting comfortably in bed with no apparent distress.

• A 75-year-old patient presents to the emergency department with classic signs of urinary tract infection, including frequency, urgency, nocturia, and dysuria. Patient was prescribed outpatient antibiotics for the UTI but was not compliant with the regimen, presenting to the ED with worsening UTI and exhibiting some early signs of sepsis. Query was issued on day two for sepsis using appropriate clinical indicators for sepsis and encephalopathy. The physician in his H&P stated in the physical exam under constitutional, once again alert and oriented in all four quadrants. Progress note under clinical impressions contains the documentation of sepsis with partially treated UTI, as well as encephalopathy secondary to sepsis.

What are the specific ramifications of issuing these noncompliant queries? Ultimately, these types of queries contribute to unnecessary, avoidable, and costly DRG validation and clinical validation denials that require ongoing administrative burden associated with a lengthy, arduous appeals process. Every hospital is experiencing escalating clinical validation denials and DRG validation downcodes associated with cases billed with one major comorbidity or complication (MCC) or CC, making for easy picking, ripe for takebacks and refuting of diagnoses by third-party payers.

There is no doubt in my mind that flaws in CDI and the query process contributes to increasing denials currently being experienced, adding to concerns over closely watched key performance indicators and costs to collect.

Another Potential Ramification: The Noncompliant Query
Another potential ramification of noncompliant queries is rooted in the medicolegal environment. There have been, from time to time, instances in which a query construed to be noncompliant was caught in the deep web of a malpractice case, wherein the question arose if the CDI specialist issuing the query was attempting to report what was alleged to be an untoward outcome of care in a potentially positive light through the actions of a clinical clarification query. There have been times, likewise, when a CDI specialist was deposed as part of legal proceedings of such a case. There is simply more than meets the eye here, with significant potential downstream ramifications for noncompliant queries, regardless of whether they adhere to the guidance in the AHIMA guidelines.

Word to the Wise
A word to the wise for all CDI professionals is become more cognizant of the entire clinical picture of the record, as opposed to focusing upon the clinical indicators as justification for a compliant query. A compliant query requires the ability to understand and appreciate the extent, depth, and breadth of the documentation, which should sufficiently communicate each patient’s story. I have always advocated for CDI to focus upon and remain committed to enhancing the value and completeness of communication of patient care for all the right reasons, notwithstanding the material benefit to the patient of furthering fully informed, coordinated, quality-focused care. Coupling this philosophy of clinical documentation integrity that embraces a true and accurate reporting of the patient’s story and being able to find the patient in the story will go a long way toward ensuring a compliant medical record, with coding and billing for optimal reimbursement.

Today’s approach to CDI puts the cart before the horse. It simply is not possible to achieve a compliant query without complete and accurate documentation that best communicates patient care.

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