Health Information Management

Verbal queries: Let your policies and procedures do the talking

CDI Strategies, May 14, 2009

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Verbal queries remain a source of contention for hospitals simply because these queries are difficult to audit and monitor. CDI specialists risk leading physicians to document a particular diagnosis during the course of a conversation which was originally meant only to clarify existing documentation. And if your query policy and procedure doesn’t at least address verbal queries, you may want to rethink your strategy.
 
Not sure where to start or what specific language to include? Tune into HCPro’s May 19 audio conference Query Policies and Procedures: Ensure Consistency and Compliance Across Your Facility, during which experts Melissa Ferron, RHIA, CCS, president, Melissa Ferron Healthcare Consulting, LLC, and Diana McWaid-Harrah, MS, RHIA, CCS, CPC, director, revenue integrity & medical coding, UCLA Healthcare, will provide guidance on how to create an all-encompassing policy that addresses verbal queries as well as several other facility-specific questions that hospitals should ask when developing a policy (including sample language you can adapt to fit your needs).
 
Consider the following tips on which the speakers will elaborate during the program:  
Tip #1: The verbal query should be designed to communicate the request for documentation clarification based on existing medical record clinical documentation.
 
Tip #2: Documentation of the verbal query in your hospital’s query tracking system is recommended.
 
Tip # 3: Consider adding the following language to your query policy and procedure:
‘The clinical documentation specialist may discuss the clinical findings and documentation with the physicians involved in the care of the patient. The role of the clinical documentation specialist is to educate the physician on the specificity of verbiage which can result in improved capture of severity of illness. In addition, the clinical documentation specialist will pose verbal queries (questions) to the physicians so that clarification may be documented. 

Under no circumstances will the clinical documentation specialist tell the physician what to document.

The clinical documentation specialist will document the following information on the patient concurrent review worksheet:

  • Date of discussion with physician
  • Physician name
  • Summary of discussion’
Editor’s Note: For information about the agenda, speakers’ bios, or to listen to an audio clip preview of the program, visit the HCPro Marketplace or contact Senior Managing Editor Lisa Eramo at leramo@hcpro.com.



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