Hospitalists should, by now, be very familiar with documentation improvement queries submitted by clinical documentation and coding specialists for clarification of diagnostic and procedural information.
Historically, when medical records had deficiencies, they were assigned to physicians to complete missing information such as discharge summaries, operative reports, and signatures on verbal orders. In 2001, CMS allowed the use of physician documentation queries to the extent that they provided clarification of conditions that was “consistent with other medical record documentation.”
Documentation queries are meant to clarify documentation so that the ICD codes assigned are accurate and optimal to ensure proper reimbursement and quality scores. As such, they form an essential part of any hospital clinical documentation improvement (CDI) program, but since coding rules and terminology often differ from common clinical language, there is a risk that the information gets lost in translation.
CMS does not allow direct questions about a specific diagnosis because it considers them “overly leading.” Hence, the only way that CDI and coding professionals can compliantly clarify documentation is with a written documentation query that includes clinical information related to the condition in question and usually offers multiple-choice response options. Yes or no questions are less commonly employed.
When ICD-10 was implemented in 2016, the number of diagnosis codes jumped from 14,000 to 69,000. It allowed for greater specificity of most clinical conditions, and for some but not all conditions, specificity became more important. Since then, many hospitals have begun using analytic systems that use ICD-10 data to try to improve reimbursement, as well as mortality rates, complication rates, and other quality measures. In the last five years, hiring of CDI specialists has exploded as hospitals expand their CDI teams.
As a result, documentation queries have increased substantially. Some physicians may find this burdensome and time-consuming. Queries may be vague or may include so much clinical information that it is difficult to discern what needs to be clarified. In some instances, the needed information can be gleaned from the medical record without further physician documentation or queries. For example, a CDI or coding specialist can determine whether a condition is present on admission based on the clinical indicators at the time of admission, see that a diagnosis of pneumonia documented on admission was ruled out based on negative chest X-ray and discontinuation of antibiotics, or recognize that the laterality of a fracture is identifiable from imaging reports.
Compounding the problem is the fact that some CDI programs have set an arbitrary clinician query rate (e.g., 35%) as a performance measure for their documentation specialists. This problematic practice has been exacerbated by artificial intelligence applications that identify large numbers of “potential conditions” for every inpatient record, prompting CDI specialists to query the clinician even if the condition has no impact on reimbursement or quality. Worse yet, clinical indicators often do not fully support documentation of these “potential” conditions, which could lead to overdiagnosis when a clinician doesn't fully review the record to determine the validity of the condition after being queried.
As a result, unnecessary queries can lead to overdiagnosis, overcoding, and overpayment. But there are solutions. Hospitalists should be familiar with the diagnostic criteria and documentation needs for commonly queried conditions like encephalopathy, respiratory failure, and acute kidney injury. Hospitalists can work with health information management (HIM) and CDI leadership teams, including their physician advisors, to ensure that only pertinent queries for essential information are being submitted.
It can be helpful for hospitalists to request a summary of the volumes and types of documentation deficiencies they are receiving in order to prospectively address them before a query is submitted. Feedback from clinicians can also improve the query process. Finally, CDI/HIM departments should reconsider arbitrary query rates as a performance measure for CDI specialists. After all, the goal of CDI programs should be to educate clinicians and reduce the volume of queries.