September 14, 2015

The ICD-10 Final Countdown Coding Checklist, Physician Coding Queries: Part 2

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In these final few weeks prior to ICD-10 implementation, your coding countdown checklist should include several key and critical points to consider. The appropriate steps along this countdown path are important to follow and observe. Make sure you have coding/physician queries on that list.

 

In today’s regulatory and compliance world, we cannot miss a beat when it comes to ethical and proper physician queries. Whether the query be from coding professionals, clinical documentation improvement (CDI) staff, or even initiated from other staff that perform documentation clarification activities and functions, all must follow ethical standards. 

The American Health Information Management Association (AHIMA) has been a strong leader on physician query practices, and it has developed three query practice briefs, starting with 2001’s “Developing a Physician Query Process.” In 2008, the next practice brief was released, “Managing an Effective Query Process.” The latest physician query practice brief was released in 2013 in collaboration with the Association for Clinical Documentation Improvement Specialists (ACDIS), and it was titled “Guidelines for Achieving a Compliant Query Practice.” The gold standard is to use and follow these practice briefs in your coding and CDI programs and activities.

Within the 2013 brief there is a strong emphasis on when to consider a query: specifically, for medical record documentation:

  • That is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent
  • That describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis

Also, the following points are important:

  • A query should include clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure
  • A query should provide a diagnosis without underlying clinical validation
  • If documentation is unclear for present-on-admission indicator assignment, a query is warranted

As for query types: open-ended queries are preferred, according to the practice briefs; however, multiple-choice and yes/no queries are acceptable under certain circumstances.

The key with developing a compliant query is to not to lead the physician to a diagnosis/condition or procedure.

A few readiness steps to take: first, gather a list of the diagnosis and/or procedure titles or diagnoses that you typically query on today (over the last 12 months). Add up by volume your queries by diagnoses (type), i.e. COPD, for example. Sometimes the results of this can be a little surprising. And if you don’t have this data available, you may have a manual (paper-based) process that you can use. In the future, you should plan to change from paper queries to electronic and capture on a monthly basis your total queries, the diagnosis or procedure types, responses and nonresponses, etc.

Now take your query diagnoses and compare the wording and language specificity in ICD-10 classification. This will require a joint effort between coding/HIM (health information management) and CDI staff. Walk through the codebook chapters, starting with sepsis in Chapter 1 (Certain Infectious and Parasitic Diseases, A00-B99). Make sure your query language is helping to capture the specificity in the subcategories. Look over the code categories and subcategories for sepsis. Also in Chapter 1 are tuberculosis, meningitis, herpes, and viral hepatitis, and these also may warrant specific documentation to capture patient severity and acuity – so be sure to review them as well.

Take a look at your current query language in each of your physician queries, whether they are templates or not. Determine whether revisions or updating is needed to reflect ICD-10 classification specificity. Follow the guidance in the 2013 practice brief regarding multiple-choice and yes/no queries, as these are to be used in only certain circumstances.

The next step is to take your revised queries and have your physician champion or a small group of physician leaders review them. This can aid in obtaining physician engagement and also provide a different perspective as to the disease/condition being queried. Once finalized and in place, either electronically or using paper, begin using the new queries now. There is no reason to wait, as the more exposure and awareness of the specificity and language changes with ICD-10, the better.

See the Excel spread sheet below, which lists the different aspects to capture for your completion of this checklist task. Documenting your steps and work is very important, and it also helps with staying organized.

Another area to make note of in relation to documentation queries is that under the Inpatient Prospective Payment System (IPPS), you’ll find the new list of ICD-10-CM codes that are CCs/MCCs (complication comorbidity and major compliance comorbidity) starting Oct. 1. A look at the CC/MCC list can be helpful in comparing diagnoses to those you query for most often. You can locate this information by going to the Centers for Medicare & Medicare Services (CMS) website.

You’ll find several tables and attachments here. The lists of CCs/MCCs are located within the following tables: Tables 6B-6M and Tables 6P.1a-6P.2a. Include in your coding readiness checklist “physician queries” and look over diagnoses that are common to severity, acuity, and risk of mortality capture, like those in the CC/MCC IPPS 2016 rule and tables.

A checklist is really a type of informational job aid used to reduce failure by compensating for potential limits of human memory, attention, and volumes of tasks. Being ready and using a checklist for all the ICD-10 tasks and activities can be extremely helpful.

Next week we’ll discuss coding policies and procedures as well as coding job descriptions as components of your ICD-10 coding readiness checklist.

 

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer

Gloryanne is a coding and HIM professional with 40 years of experience. She is the past president of the California Health Information Association. Gloryanne is a member of the ICD10monitor editor board and is a popular guest on Talk Ten Tuesdays.

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