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By Karen Newhouser, RN, BSN, CCDS, CCDS-O, CCS, CDIP, CCM from the ACDIS CDI Blog
As the CDI and coding professions continue to evolve, query guidance methods have changed along with them.
The first industry standard brief, “Developing a Physician Query Process,” published by AHIMA in 2001, set the foundation for the compliant query practice.
In 2008, “Managing an Effective Query Process” continued the path of compliant querying. This brief approved the use of yes/no queries for present on admission queries only, and it asserted that a query shouldn’t mention an impact on quality reporting (in addition to a financial impact).
The most significant change between these two documents was the increased use of the term provider to mean physicians and other qualified healthcare practitioners in the latter brief. That change reflects an overall shift in healthcare to change verbiage from physician to provider. In the past, the term provider was reserved for hospitals and facilities to identify the provider entity in terms of payer/ payee context. The term physician was used to identify the healthcare professional providing services to the patient. But as the utilization of mid-level providers, such as nurse practitioners, certified nurse-midwives, certified registered nurse anesthetists, clinical nurse specialists, and physician assistants grew, the verbiage was not as appropriate. These professionals underwent advanced schooling to earn licenses allowing them to establish a diagnosis and dispense medication, among other duties, but they aren’t physicians. Hence, another name was sought to encompass this growing group, and the name provider supplanted the term physician. This name change mimics a directive from the ICD-10 Official Guidelines for Coding and Reporting, which states, “The term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis.”
In 2013, ACDIS and AHIMA joined forces to publish “Guidelines for Achieving a Compliant Query Practice,” with a small revision in 2016 to update to International Classification of Diseases, 10th Revision (ICD-10) verbiage. This brief broke from keeping the development of queries at the general, overview level and emphasized compliance by focusing on relevant clinical indicators/evidence and reasonable options. The terms clinical indicators/evidence saw a significant increase in use over the previous query brief. The brief also greatly expanded the circumstances where a yes/no query could be used.
As the profession evolves to the outpatient environment, ACDIS published a position paper in 2018, “Queries in Outpatient CDI: Developing a Compliant, Effective Process,” which addresses the uniqueness of the outpatient setting, including the use of prospective queries and use of prior encounter information in any query. Additionally, it highlights the guidelines and rules that are exclusive to the outpatient setting due to the method of reimbursement and to whom reimbursement is being provided.
In 2019, ACDIS and AHIMA updated their guidelines for inpatient queries via the new “Guidelines for Achieving a Compliant Query Practice (2019 Update),” which continues the focus on clinical indicators, documentation support, and compliance while establishing a standard on the use of information from prior records in a query.