Query forms: Groups look for a way to avoid hints of fraud and abuse 

Organizations now await a CMS directive

The need for timely and complete documentation warrants the acceptance of physician query forms as part of the medical record, two health organizations recently told the Centers for Medicare and Medicaid Services (CMS). The American Hospital Association (AHA) and the American Health Information Management Association (AHIMA), both in Chicago, testified on July 27 at a meeting convened to discuss the use of coding summary forms. The forms, called physician query forms, are used when the record is reviewed by a Peer Review Organization (PRO) to validate diagnosis-related group (DRG) coding. CMS and the Office of the Inspector General (OIG) are concerned that some query forms may lead the physician to make a decision or to write a description that would support the inappropriate upcoding of a DRG. Therefore, CMS (formerly the Health Care Financing Administration) issued a policy memorandum to PROs in January directing them not to accept coding summary forms as documentation in the medical record following DRG validation procedures specified in section 4130 of the PRO Manual. The policy memorandum generated a high level of public interest. CMS says it recognizes there are various interpretations of what constitutes proper supplemental usage of coding summary forms. The agency then delayed the new policy until Oct. 1 so it could seek individual input from everyone involved. Sue Prophet, RHIA, CCS, AHIMA’s director of coding policy and compliance, testified that not all query forms should be viewed with suspicion. "We believe the vast majority of query forms are not used with fraudulent intent, and therefore, that using query forms should not immediately be interpreted as an indication of fraud or abuse." Query forms are needed in health care today, she said. "In our imperfect world, many times, documentation is not complete, or timely, or accurate. 

AHIMA members are therefore charged by their facilities, Correct Coding Guidelines, and the AHIMA Code of Ethics, to take action to ensure that missing or questionable documentation, or lack of documentation, is reconciled in order to ensure a complete record and accurate coding. It is this action that led many facilities to establish a query process." "There is a long-standing tradition of medical records staff querying physicians for additional information when it comes to correct coding," testified Nelly Leon-Chisen, RHIA, director of AHA’s Central Office on ICD-9-CM. "The 1990 edition of Coding Clinic states, The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation, the application of all coding guidelines is a difficult, if not impossible, task.’ Coders have been struggling with incomplete documentation for many years and will continue to struggle until the natural language of physicians conforms to coding conventions." The need for correct clinical coding is also important for benchmarking, quality assessment, research, public health reporting, and strategic planning, in addition to reimbursement, she says. "Without accurate reporting of clinical codes, these critical activities are threatened." She asked that CMS consider the following implementation issues regarding physician query forms: 

• There should be a consistent national standard across federal programs regarding the appropriateness of physician query forms. 

• There should be a logical and ethical basis for the query. Query forms should seek clarification only, not steer the physician to a particular code. 

• There should be a formal physician query process and written documentation of the communication between the coder and the physician. This physician query form should be a formal part of the medical record, approved through the hospital’s internal channels. 

• Query forms should allow case-specific customization to allow coders the flexibility to carefully formulate the rationale for the query as well as the diagnosis, symptom, condition, or procedure in question. 

• The physician’s response on the query form should be accepted as valid documentation to substantiate code assignment. 

• When query forms are used appropriately, the peer review organizations should be permitted to use the information obtained for DRG validation. 

Prophet proposed that the CMS take a new approach on determining situations where the use of physician query forms might be cause for further investigation. She recommended that PROs be instructed to look for patterns of coding errors in cases of concern. Prophet also recommended that facilities monitor their use of queries and provide education to physicians on the proper documentation of a diagnosis when documentation is repeatedly provided inadequately. "CMS’ discussion on queries has already raised that there are good and bad query processes," she said. "AHIMA’s approach to queries is to ensure that the query process should be in place to improve physician documentation and coding professionals’ understanding of the unique clinical situation. We further suggest that the facility and its physicians be involved together in developing its query policy and procedure." Overall, about eight individuals testified at the town meeting, says Dan Rode, MBA, FHFMA, AHIMA’s vice president of policy and government relations. A few others made comments, and CMS gave an overview presentation. "Most indicated a desire to see query forms continued," he says. "I believe there were good suggestions on how to do this and what rules the PROs could follow."