February 2009

Teamwork and the Query Process under MS-DRGs

By Shannon M. Boyer, RHIA

On October 1, 2008, CMS completed a three-year transition from the Diagnosis Related Group (DRG) prospective payment system to Medicare Severity-DRGs (MS-DRGs). The change was made to provide added focus to the severity of a patient’s illnesses, as opposed to previous methods which took an “all patients are created equal” approach if the patients shared a given disease process.

As a result of the MS-DRGs implementation, coders and other HIM professionals have  enhanced and fine tuned their professional skills, and expanded their clinical knowledge to levels higher than were previously necessary. An understanding of the impact of all codes – even those that were previously considered insignificant under old systems, such as V codes – has become essential to ensuring proper assignment.

Communication between coders, physicians, nurses, and other health care staff is crucial to proper coding. The processes needed for this new system have lead to an increased focus on teamwork in order to obtain all appropriate clinical documentation necessary for correct coding. Many facilities utilize a team composed of coders and case managers who concurrently review the records during admission. The coders can assist the case managers by increasing their understanding of the proper documentation requirements and coding guidelines. Another example of how teamwork can lead to proper coding is when case managers who spend time in patient care areas on a daily basis reviewing charts, can seek clarifications from physicians on the spot. Another effective method is to employ documentation specialists who have an understanding of coding clinical aspects of health care, and who are able to perform reviews, and generate queries. An effective and compliant physician query process should be in place to capture pertinent data, preferably while the patient is hospitalized as this will reduce the number of post discharge queries. 

In further addressing the precise purpose and use of queries, we refer to The American Health Information Management Association (AHIMA), which recently published an updated practice brief, Managing an Effective Query Process (Journal of AHIMA 79, no. 10, October 2008), which defines a query as a question posed to a provider to obtain additional, clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis, and procedure codes in a patient’s health record. 

All queries should adhere to AHIMA’s Standards of Ethical Coding guidelines, regardless of who initiates them. It is recommended that all queries be written with documentation from the record, and that they clearly ask the provider to include a clinical interpretation of the information. Queries should not be leading or suggestive in any manner, nor should they reveal the financial impact of an answer or contain information pertaining to previous visits that are not documented in the current patient encounter. A query form can, however, address multiple issues at once, as long as a specific question is asked in reference to each issue. Yes/No answers are not recommended, with the exception of clarification on POA. 

Check boxes may be used if there is an option for selecting “other” or “unable to determine.” It is also advisable to leave blank space so that the provider may enter additional information or documentation he believes is relevant to the query. This method gives guidance to providers so that they are aware of what further specifications coders require, but it also allows for open-ended questions and answers in order to illicit proper, unbiased responses from the providers. In addition, some facilities require the provider to initial a check box.

To ensure that queries are appropriate, each facility should implement a policy that establishes when one should be initiated. In accordance with the October 2008 practice briefing, queries may be filled out for the following situations:

• Clinical indicators of a diagnosis but no documentation of the condition.
• Clinical evidence for a higher degree of specificity or severity.
• A cause-and-effect relationship between two conditions or organisms.
• An underlying cause when admitted with symptoms.
• Only the treatment is documented (without a diagnosis documented).
• Present on admission (POA) indicator status.

The goal is to obtain accurate data that will reflect the true severity of afflictions suffered by patients. Utilizing a query form properly will help your facility obtain the necessary information while still adhering to proper coding ethics and guidelines. Ongoing communication between HIM staff and providers is key under the new MS-DRG system.

Editor’s note: Shannon Boyer is a coding and auditing consultant in Burlington, North Carolina for Clinical-Insights.

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