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In an ideal world, physicians would document their care correctly and completely in the medical record, giving coders all the tools to do their jobs. But the ideal is seldom real life. In the real world, coders often have questions that must be answered before they can code appropriately. Sometimes they use a query form to ask physicians about incomplete documentation. Physicians can respond by adding documentation to other parts of the medical record or responding on the query form itself, rendering it part of the record.
Now the Health Care Financing Administration (HCFA) says query forms cannot be considered valid documentation in the medical record. This policy has sparked debate on health information management listservs and has frustrated the American Health Information Management Association (AHIMA) in Chicago. AHIMA raised this issue with HCFA in a November letter and suggested that it work with HCFA to develop a query process that would comply with Medicare regulations.
HCFA’s response — and new policy — was outlined in a Jan. 22 memorandum to its peer review organizations (PROs): "Effective immediately, PROs are not to accept coding summary forms [e.g., Physician Query Forms] as documentation in the medical record when following DRG [diagnosis-related group] validation procedures within their jurisdiction, as necessary to ensure proper documentation within the medical record."
HCFA is concerned that some query forms may lead the physician to make a decision or to write a description that would support the inappropriate upcoding of a DRG, explains Dan Rode, MBA, FHFMA, AHIMA’s vice president of policy and government relations, who says HCFA believes that all query forms are suspect and therefore wanted to eliminate them.
Unfortunately, HCFA used quotes from a book written by an AHIMA staff member to support its argument. The quotes suggest that a complete medical record is ideal, one that has all of the information necessary and is only handled by the physician — without the use of query forms.
"That is certainly what we strive for in our best practices and in the other things that we do with our members, but we have situations that are not the ideal. The query form then becomes necessary," Rode says.
AHIMA addressed the query form issue in a Feb. 12 letter to HCFA. "We are trying to do as much as we can to work with [HCFA] so it understands the issue and comes up with a result that our members, their facilities, and their physicians can work with," Rode says.
Members of AHIMA’s Coding Policy and Advocacy and Policy Committees looked over the memo to the PROs and then created a list of their questions and concerns. The list is included in the February letter.
"We have now gone back and raised a number of questions about that memorandum and at the same time have extended a hand to [HCFA] to say, You just don’t turn this ship around on a dime. It’s going to take a little while. What can we do to ensure that our members [comply] with the rules that you are now attempting to establish?’" Rode says. "We recognize that right now, the rules tend to come down on the facility and the coder, and yet the physician is another large element involved."
AHIMA also noted in the letter that members are concerned that PROs do not tend to work alike. "We are concerned about this memorandum being implemented in different ways at different times with different impacts across the country," he says.
But do query letters discourage physicians from completing their documentation the first time? "It’s a two-edged sword," Rode says. "We are not in favor of query letters, per se. We would like to see documentation done correctly the first time."
Because many organizations have not been able to achieve that ideal as frequently as they would prefer, they must query the physician before they can be paid and comply with the Medicare rules. AHIMA doesn’t condone any "leading language" on the forms, Rode says. "On the other hand, there are other ways to write a query in such a way that you are not leading a physician and that you do get that response," he notes. AHIMA, however, will continue the effort to help members get complete records and cut down on the number of query forms, if not eliminate them, Rode adds.
AHIMA is also trying to ensure that HCFA is not asking coders to make decisions they are not qualified to make. "We don’t want coders coding with less than full information," he says. "Coders should be coding information in the chart. If the information is not in the chart, we need to get it there."