Five Steps to an Effective Physician Query Process

An essential component of Clinical Documentation Improvement (CDI), the physician query seeks to attain accurate code assignment and ensure documentation accurately reflects a patient’s clinical condition. They are used to address a variety of documentation issues, such as:

• Clarifying undocumented diagnoses
• Resolving conflicting information
• Identifying the reason for an encounter
• Establishing a cause-and-effect relationship

The physician query process serves as a vital communication and educational tool for CDI, medical coding, and other healthcare professionals. By seeking documentation clarification, it contributes to accurate code assignment, enhances data integrity, and ultimately improves the quality of the patient’s experience. The query process also plays an important role in reimbursement, data stewardship and collection, quality measures, medical necessity, denial prevention, and other significant healthcare initiatives.

Five Stages of Effective and Compliant Querying

To ensure the compliance and integrity of physician queries – regardless of whether the query is generated manually or through AI or computer-assisted tools or other technology – it’s important to adhere to legal ethical guidelines. This includes establishing clear policies for generating queries, monitoring compliance, conducting audits, and providing feedback to the query team.

To achieve its goal of validating clinical documentation and accurately capturing the provider’s intent for precise code assignment, an effective physician query process should encompass five stages: preparation, development, querying, response management, and education. Each stage is outlined below, and more detail is provided in our white paper, “Achieving Accurate Reimbursements by Maximizing CDI for Physician Queries.”

1. Query preparation: Establish a CDI team consisting of coders, CDI specialists, physicians and other relevant subject matter experts and stakeholders with clear roles and responsibilities. This team will identify query opportunities through a comprehensive analysis of clinical documentation and in alignment with industry standards, including those provided by AHIMA and ACDIS.
2. Query development: Questions should be clear, concise, and tailored to the patient’s clinical scenario while remaining unbiased and neutral. Queries should focus on specific clinical indicators or diagnoses requiring clarification and include supporting evidence and other relevant information, such as lab results, imaging studies, and other clinical data. Free-text response options should be included so physicians can provide information beyond the predefined choices, helping avoid misinterpretations or oversights.
3. Querying physicians: When querying physicians, the CDI team must adopt a collaborative approach, fostering open communication and mutual respect focused on improving the accuracy and completeness of clinical documentation. Building a positive relationship with physicians encourages them to engage in the query process and respond effectively. CDI teams should understand and respect the physician’s workflow, minimizing disruptions to fit requests into their daily routines. Further, when providers have follow-up questions or clarification requests, CDI teams should respond promptly.
4. Managing physician responses: When responses are received, the CDI team should thoroughly analyze the information provided to ensure it aligns with the clinical indicators and supporting evidence in the health record. If a physician’s response is incomplete or ambiguous, further clarification should be obtained to avoid assumptions. All query responses and subsequent actions taken by the CDI team should be meticulously documented, which serves as an audit trail and ensures compliance with coding and documentation guidelines. After resolving the query and obtaining a definitive diagnosis or clarification, the CDI team must accurately update the health record to reflect the most precise and complete information. Importantly, all actions taken by the CDI team in response to physician queries must adhere to coding, documentation, and legal guidelines. Compliance with industry regulations and ethical standards is paramount.
5. Query education: If common patterns of inadequate query responses emerge, the CDI team should consider providing additional education to physicians on coding guidelines and documentation requirements to help improve query responses in the future. Additionally, regular training sessions enable team members to stay up to date with coding and documentation guidelines, reinforce compliance, enhance their skills in the query process, and keep everyone informed about best practices, changes in industry standards, and advancements in technology.

Clinical Documentation Improvement: Measuring the Impact

Continuous process evaluation and measurement help identify successes and areas for improvement. CDI teams should define specific performance metrics and goals, for example query response rates, query completion times, query acceptance rates, and improvements in documentation accuracy.

Regularly analyzing query outcomes also helps assess the effectiveness of the querying process. This includes tracking the number of queries resulting in improved documentation and accurate code assignment and comparing coding accuracy before and after process implementation. A decrease in coding errors and increased accuracy are positive indicators. Additionally, tracking query response rates helps evaluate physician engagement in the process, as higher response rates indicate better collaboration and physician involvement.

Assessing the overall improvement in clinical documentation can be measured by comparing the completeness, specificity, and accuracy of documentation before and after the query process implementation, while measuring the time taken to resolve queries can identify areas for improvement in the process.

Feedback obtained from coding audits and reviews can highlight the impact of physician querying on coding accuracy and compliance and help identify areas for further improvement, while monitoring reimbursement patterns and quality reporting outcomes can indicate how effective querying has been in capturing and reflecting the true clinical picture of patients. Finally, evaluating the need for additional education and training for physicians based on query responses can help target specific areas for improvement in documentation practices.

A Catalyst for CDI Excellence

The physician query process relies on teamwork, knowledge, and effective communication to enable CDI professionals to seek clarification from physicians on clinical conditions, procedures, and other important aspects of patient care.

Through a collaborative approach, the physician query process becomes a catalyst for achieving excellence in healthcare documentation, data integrity, reimbursement accuracy, and overall quality of care. This, in turn, ensures more accurate and comprehensive patient information in health records, facilitating proper code assignment, and supporting compliant billing and reimbursement practices.

A more detailed discussion of effective physician queries can be found in our white paper, “Achieving Accurate Reimbursements by Maximizing CDI for Physician Queries.” Watch for the next post in our series on maximizing CDI for physician queries for accurate reimbursement.