| It
is my pleasure to speak on behalf of the American Health Quality Association (AHQA).
We represent the national network of Medicare Peer Review Organizations and other
institutions working on improving quality in health care. I am Mark Boesen, Director
of Government Affairs at AHQA. Thank you for the opportunity to comment on the
use of physician query forms.
AHQA has serious
reservations about any guidance that would limit the use of properly designed
query forms or their acceptance as a component of the medical record. The query
form has long been considered a useful communication tool, but not a substitute
for clear and accurate documentation. These forms have been an essential resource
for our work required under provisions contained in Section 1866 of the Social
Security Act. There is also evidence that proper procedures utilizing query forms
improve the quality of original medical documentation. There will always be incidents
requiring a coder to query a practitioner for clarification to ensure accurate
coding. Query forms can be used to perform pattern analysis of documentation deficiencies.
This analysis can then identify consistently poor or unclear documentation practices
by practitioners. Physicians are able to learn from query forms, and as a result,
improve their documentation skills.
AHQA shares the
concern about poorly constructed query forms and the informality of the forms
that currently exist in some settings. "Yellow sticky notes" requesting
permission to bill under a certain code are clearly unacceptable communication
strategies. We believe that each institution should establish a standardized process
for queries and clearly define this process in the facility's policy and procedure
manual. Examples of best practice policies include the following:
- A coding query
form should be approved as an official medical record form if the form is made
a part of the medical record;
- Query forms should
only seek clarification of information that is already present in the record in
order to assign the most specific code;
- Questions should
not be phrased in a way that leads the physician to provide the coder with a particular
answer, not just "yes" or "no"; and
- Under no circumstances
should coders be permitted to add or alter medical information in the medical
record.
Elements of a
properly designed form should include the following:
- Date of the query;
- The specific question
needing clarification;
- Identification
of the coder asking the question;
- A response area,
if applicable; and
- Instructions for
documentation of any correction or addendum in the body of the medical record.
This last point
is critical; we believe the best place for an addendum or correction is in the
progress notes or discharge summary. There should always be a process in place
to verify that documentation instructions provided in the query form have been
executed.
Disallowing the
use of the query form or disallowing its acceptance in the medical record complicates
the process of obtaining supplemental documentation from the physician, resulting
in an increased burden on already short staffed health information departments,
and delaying billing. Thank you for your time and attention to our comments.
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