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Article byHarvey Bair, RN, PhD, CCDS, CRC. This article was originally published on the Journal of AHIMA website on April 28, 2017 and is republished here with permission.
Do you find yourself wondering what to focus on when querying for ICD-10 specificity? Are you concerned that your organization’s query process may overwhelm providers? You are not alone; the entire healthcare industry is trying to figure out how to address this issue.
In the ICD-10 billing environment, many organizations are noting an increase in tension between providers and coding, CDI, quality, and reimbursement staff caused by new, unprecedented levels of demand for detail, or specificity, in physician notes to support billing requirements. Providers working on healthcare’s front lines are struggling to cope with increases in overall patient volume, and are being sent multiple queries on each patient asking for clarification or additional details in the notes they document. This leads to “query fatigue,” a phenomenon where the provider becomes frustrated with the volume of questions they are receiving on the care they are providing, ultimately choosing to stop answering queries.
To evaluate whether query fatigue is a problem in your organization, hospital leaders must engage with providers to understand both the overall level of dissatisfaction with queries and the provider’s understanding of when and why queries are sent, and how their responses are used by the organization.
Considerations for Analyzing Query Fatigue
Measuring the scale and scope of query fatigue within an organization can be an eye-opening process for hospital leaders. To begin, conduct a thorough review of current practices within departments that generate provider queries. This is critical to understanding, in detail, each department’s querying volumes and procedures. It will also identify redundancies, inconsistencies, and opportunities for process improvements, providing a roadmap for the consolidation of efforts among departments and resulting in a streamlined process and standardized templates.
The next consideration is an in-depth analysis of query data, including generation types, reasons, and response types. This will review query trends by department, service line, and provider, identifying opportunities to improve messaging, such as additional education, provider engagement, and overall effectiveness of queries.
Finally, review documentation requirements and the education process for staff and providers involved. The organization should evaluate the documentation training given to providers to increase the level of specificity they include in their notes in an effort to limit query generation.
Implementing Query Process Improvements
Provider queries have increased an estimated 30 percent or more since implementation of ICD-10, and query response rates have declined. The questions now asked are: What should we query for? Are there compliance issues if we don’t query for everything? Answers are not simple. Depending on operational initiatives impacting your organization’s priorities, discussions should take into consideration payor mix, the organization’s query philosophy, senior leadership engagement, and an impact assessment on compliance.
Payor mix will impact overall documentation priorities within an organization. Medicaid Severity DRG and Medicare MS DRG systems have different documentation requirements to capture accurate reimbursement, as do many private payors. Documentation and querying priorities must be based on regulatory requirements, payor denial trends, and CDI resources available to implement a strategy focused on accurate documentation.
Query philosophy defines what and when the organization will query. In most organizations, a Clinical Documentation Program performs concurrent queries, while the patient is in-house, in order to capture documentation before discharge. Retrospective queries, after discharge, are typically performed by HIM coding and quality departments. A philosophy should be created for both instances and be reflected in a query guideline to include: who, what, when, and how to query. This guideline should be used by all querying departments to ensure consistency and compliance.
Senior leadership engagement is critical to ensure a successful documentation program. Senior leadership should understand the impact of documentation and that it is not based on reimbursement alone but also includes regulatory, public reporting, and quality outcomes. Many organizations have cut budgets in departments that drive documentation-clarification activities, which, in most cases, has resulted in declines in reimbursement and quality scores, poor public outcomes reporting, and increased denials. Senior leadership must be educated on the roles and responsibilities of each department’s documentation requirements and its impact on the organization.
Compliance integrity plans play a significant role in prioritizing documentation capture and integrity standards. Compliance should be involved in all decisions pertaining to queries and processes. By including compliance in the query workflow, departments will receive critical organizational information such as the choice of integrity plan. For example, if an organization enters into an OIG integrity plan for documentation issues related to querying, coding, or billing, all querying departments should understand the issue and details within the plan so that compliance is maintained across the organization. This is becoming increasingly important as regulatory and payor reimbursement requirements are changing rapidly, demanding that organizations ensure that all departments, especially those that impact reimbursement and outcomes measures, are compliant with standards and practices.
The question to query or not to query will be specific to the individual organization and will evolve based on internal data analytics, regulatory compliance, and industry standards. Organizations must recognize and address provider query fatigue in a timely manner, as it can have major impact on reimbursement, quality, and regulatory compliance outcomes measures. Remember, the issue is not the ICD-10 code, but rather the provider documentation to support an accurate code assignment, and the process through which that is achieved.