Documentation in the health record is a basic but critical component to every patient encounter, patient service, and setting. The provider is key to delivering detailed information regarding the patient's chief complaint, present illness/history, past medical/surgical history, family history, and physical examination. These details are all a common part of health record documentation, especially in the physician office setting.
All entries in the health record must be complete, accurate, and authenticated. Although the hospital setting has been a primary focus of attention surrounding clinical documentation improvement (CDI), it is just as important that clinical documentation in the physician office setting is complete, accurate, and authenticated.
Within the healthcare industry, reimbursement methodologies rely on capturing severity of illness, risk of mortality, acute and chronic conditions, medical necessity, quality measures, and value metrics such as the Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP). These are all directly or indirectly driven by clinical documentation and coding. The coding of diagnoses, signs/symptoms, procedures, and/or services in the physician office setting requires both ICD-10-CM and CPT to be coded to the highest level of accuracy, certainty, and specificity.
The process and practice of utilizing "physician querying" historically dates back in time to the hospital inpatient prospective payment system in 1983-84. CDI, facilitated through the physician query, is the healthcare industry practice and process that obtains clarification when the documentation is incomplete, nonspecific, conflicting, or not present at all. Individuals who are trained and educated about the query process, primarily CDI and coding professionals, address the provider with issues, concerns, and questions regarding the encounter documentation. This powerful communication process applies to all healthcare settings. For the physician office setting, this can be performed at the time of the encounter, immediately following the encounter, or retrospectively (post-billing/payment).
The AHIMA Practice Brief titled "Guidelines for Achieving a Compliant Query Practice" applies to all settings, including small physician offices and large physician group practices. The benefits of accurate, complete, and specific documentation is as relevant in the office setting as it is in the hospital setting. Following both the guidelines in that Practice Brief and this more focused article are good steps toward ensuring integrity and compliance are incorporated into the physician office query and CDI process.
There are three appendices with additional content published in the online version of this Practice Brief in AHIMA's HIM Body of Knowledge at http://bok.ahima.org:
CDI involves a thorough review of the health record documentation to ensure it's accurately reflecting the severity of illness, risk of mortality, and clinical care provided to and for the patient.
Preventable medical errors occur with alarming frequency in US hospitals. Unavailable patient information and illegible handwriting have led to diagnosing and ordering errors, which compromise patient safety and quality of care. Regulatory agencies and healthcare providers have recognized that by focusing on the integrity of clinical documentation, a traditional hospital can improve patient care, improve reimbursement, and report accurate data, which reflects the highest standards of patient care. The implementation of a CDI program plays an important role in achieving these goals for physician office practices.
The increased prevalence of risk-based healthcare plans and the emphasis on quality initiatives has begun to demand the need to focus across the healthcare continuum to include the clinic. A key component of this shift is the increased awareness of Risk Adjustment (RA) and Hierarchical Condition Categories (HCCs), which further emphasizes the need for CDI and physician education in concepts that will aid better documentation to capture diagnoses to the highest specificity.
It is industry standard for health plans to review medical records retrospectively (commonly referred to as chart review) for Medicare Advantage (MA) plans for risk adjustment payment accuracy. Regulations allow for submission of new diagnosis codes for up to two years after the date of service. During the chart review process, health plan coding professionals may review encounter documentation that is incomplete, nonspecific, conflicting, or not present at all. At this time, it may become necessary to initiate a physician query to ensure accuracy of the documentation and code assignment. This is particularly relevant in situations where ICD-10-CM does not provide code assignment for nonspecific terms, such as lupus. When physician queries are initiated during chart review within the regulatory window, the queries should be limited to requesting the physician to interpret or clarify their own documentation. An example of this would be documentation of "CKD, GFR 17," where a query is initiated to clarify the stage of the CKD. While the provider is clinically specific, the verbiage does not align with the correct code assignment unless the physician specifies the stage.
The Medicare Access and CHIP Reauthorization Act (MACRA) is one of the initiatives that is moving CDI to the outpatient arena. MACRA includes various payment models that allow the provider to customize their focus on care delivery and outcomes. It includes the need to show patient risk through HCC coding and justify the need for services with some old concepts such as medical necessity. Sometimes in that setting, coding professionals are called upon to wear multiple hats, including being the first line of defense for CDI. But the entire team, including scheduling, nursing, and others, can relieve some of the burden for providers by identifying gaps and needs for more specific documentation before it reaches the coding stage. Focusing on frequently treated diagnoses and chronic illnesses will be a valuable effort under value-based payment. The quality measures under MACRA are very specific, and clinical documentation will need to match or exceed that level of specificity for physicians to be successful when participating in these programs.
CDI programs are also crucial in validating that the physician office receives appropriate and accurate reimbursement. It is a known fact that reimbursement is driven by coding and coding is driven by documentation. Compliant clinical documentation also supports accurate quality of care reporting.
Education on the linkage of clinical documentation to the many aspects of healthcare will be helpful to the physician practice. As adult learners, there are many verbal and written educational styles a CDI specialist can utilize when providing education to physicians and the office staff. Education for office staff, including physicians, will help to achieve the goals and benefits of CDI.
The six quality domains of healthcare quality, according to the Agency for Healthcare Research and Quality (AHRQ), can guide the development of CDI education for physicians in the office setting.
Avoiding harm to patients from the care that is intended to help them.
Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively).
Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.
Reducing waits and sometimes harmful delays for both those who receive and give care.
Avoiding waste, including waste of equipment, supplies, ideas, and energy.
Providing care that does not vary in quality among groups of those with varying personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.
It is important for physicians to know that their documentation impacts the quality of patient care reporting, physician performance profiling, and accurate payment. To improve clinical documentation, physician practices must identify deficiencies, inconsistencies, and discrepancies in current clinical documentation. It is beneficial for physician offices to adopt a CDI education program within their day-to-day practice. This model will assist in the capture of not only acute but all chronic conditions/statuses impacting patient care. Without adequate tools and procedures for accurate and complete documentation at the point of care, patients can be exposed to medical errors. A single mistake can threaten the stability of a medical institution and may even destroy the lives of the patients. Liabilities, failures, and risks can be prevented by implementing improvement programs which promote modern tools, programs, and applications for clinical documentation.
Each physician office will vary in the structure of their query process. This process may be developed in a new department or incorporated into other roles. CDI professionals who work in a physician office setting can come from a variety of professional backgrounds, such as nurses, coding professionals, office managers, scribes, and more. Each practice should work with the practice leaders, providers, and frontline staff to determine the best structure for their query process.
A query is a clarification request that is sent (delivered) to the provider (physician, nurse practitioner, physician assistant, etc.) who is legally responsible for the care of the patient as well as determining a diagnosis. Synonymous terms for "query" include: clarification, clinical clarification, documentation alert, documentation clarification, and similar terminology.
The following are important rationale for a physician query:
Clinical documentation provides valuable information essential to quality care. Quality reporting helps patients choose caregivers and is increasingly tied to reimbursement, making high-quality documentation vital for providers.
Since MACRA's initiation, physician reimbursement is shifting to pay-for-performance. Risk adjustment (RA) methodology bundles patient comorbidities into CMS HCCs to appropriately compensate for differences in patient outcomes. Both Medicare Advantage and E/M codes rely heavily on documentation and coding to capture patient complexity. Comorbid conditions must remain actively documented on the problem list to accurately reflect severity of illness and support accurate reimbursement.
Procedures such as treadmill tests and pulmonary function studies require medical diagnoses to satisfy coverage determinations for reimbursement. Many diagnoses require increased specificity to meet medical necessity, including for Bundled Payment for Care Improvement (BPCI).
Precise and thorough documentation defends against regulatory reviews by allowing conditions to be clinically validated through well-documented provider notes based on criteria accepted by the medical community.
Queries may be initiated in response to coding audits when documentation is incomplete, nonspecific, or conflicting. These clarify the physician's own encounter notes and are documented as an addendum, becoming a permanent part of the medical record.
Queries may be made in situations such as:
It may be appropriate to generate a provider query when documentation in the patient's health record fails to meet one of the following seven criteria identified below:
Practitioners should review previous encounter documentation that will impact direct patient care across the continuum. Some of the clinical information impacting an encounter for the physician office may come from a previous encounter or workup that was ordered in preparation for the visit and current patient care. For this reason, previous encounter information in the outpatient setting may be referenced in queries for clinical clarification and/or validation if it is clinically pertinent to the present encounter. However, it would be inappropriate to "mine" previous encounter documentation to generate queries not related to the current encounter. The composition and format (layout and design) of the query itself is very important in achieving a non-leading and compliant process.
Queries may be either verbal or written and may be generated in one or more of the following ways:
Written queries, whether paper or electronic, should be made utilizing compliant query templates:
Yes/No queries are to be utilized in an outpatient setting under the following circumstances:
Use of AHIMA query templates (see the AHIMA Practice Brief "Guidelines for Achieving a Compliant Query Practice" and AHIMA's Query Toolkits) is highly encouraged, with only the following edits:
Verbal and telephonic queries will follow the same format and requirements as written queries. All queries will be:
The query should contain all of the patient's identifying information such as name, date of service, and health record number. Queries may be initiated by professionals trained and educated in the compliant query process. The contact information (name, telephone, email) of the professional who initiated the query should be provided.
All queries should be logged for follow-up to track responses and to trend any documentation issues which may indicate additional documentation improvement educational opportunities for providers or overuse of queries by trained professionals.
The following guidance regarding medical record documentation was included in CMS Transmittal 47:
All entries in the medical record must be complete. A medical record is considered complete if it contains sufficient information to identify the patient; support the diagnosis/condition; justify the care, treatment, and services; document the course and results of care, treatment, and services; and promote continuity of care among providers. With these criteria in mind, an individual entry into the medical record must contain sufficient information on the matter that is the subject of the entry to permit the medical record to satisfy the completeness standard.
All entries in the medical record must be dated, timed, and authenticated, in written or electronic form, by the person responsible for providing or evaluating the service provided.
In addition, CMS Transmittal 442, Change Request 8105, effective January 1, 2013, has given some guidance for healthcare providers:
Providers are encouraged to enter all relevant documents and entries into the medical record at the time they are rendering the service. Occasionally, upon review a provider may discover that certain entries, related actions that were actually performed at the time of service but not properly documented, need to be amended, corrected, or entered after rendering the service.
With respect to the above, it is well known that healthcare quality and data are gaining more importance, and key elements include the coded data—which comes from the clinical documentation in any healthcare settings. This is particularly focused on the diagnoses, signs/symptoms, procedural services, and encounter details. However, when looking further at that clinical documentation for coding, one finds there are opportunities for improvement through clarification. Through partnerships, collaboration, and processes that function with the highest degree of integrity, documentation improvements can be obtained.
Utilizing the physician query in a physician office setting as a communication tool is a recommended process of asking a question in order to obtain the necessary clarity, specificity, and completeness of the clinical documentation. If the query process is followed in accordance with industry standards (such as those outlined in AHIMA's Practice Briefs), guidelines, and regulatory directives, there can be significant positive impact on the quality of the provider's documentation as well as the potential of reduced compliance risk.
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