Health Information Management

Q&A: Clinical conversations vs. leading queries

CDI Strategies, May 24, 2012

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Q: Are clinical staff held to the same standard as coders and CDI staff regarding leading questions and queries?  For example, when the nurse tells the physician the patient is obese (or he/she thinks they have a medical condition, such as pneumonia, etc.), is this considered a “leading query?”

This is coming up specifically because our birth center triage has a discharge order set where the nurse, during a phone conversation with the physician, checks off appropriate diagnoses regarding why the patient was seen.  Examples could be previous fetal loss, obesity, etc.  The physician could be someone on call who doesn't know the patient well, or the RN could be reminding the physician details about their own patient.
 
I (personally) don't see this as "querying." I see this as conversation between clinical staff, allowing them to capture the appropriate information they need to take care of the patient.  However, some in our organization feel this is querying and needs to follow the same guidelines and restrictions as coding a CDI. What are your thoughts?
 
A: I know everyone hates this answer, but it depends. If the clinical staff is part of the treating medical team then they are not leading the physician. They are reporting abnormal findings and/or bringing pertinent issues to the attention of the physician as part of the care of the patient. 
 
However, the CDI staff is not part of the medical team. 
 
Regarding your specific situation, this scenario should be acceptable as long as the attending/treating provider signs the discharge order set because coders can’t code from nursing documentation.  It is a common practice for nurses to take verbal orders from a physician.
 
Additionally, it’s common practice for the nurse (who is part of the medical team) to provide information relevant to patient care (e.g., remember this patient has an allergy, so are you sure you want antibiotic XYZ?). Nurses have always “had the provider’s back” so to speak as patient advocates reminding them of pertinent elements of the patient’s care.  
 
Also, most agree that when the CDI staff accompany the medical team on rounds or engage in general discussions with the medical team about documentation issues, this practice is considered education, not querying. 
 
In short, if the CDI specialist approaches the medical team about a particular patient regarding a particular issue, this is a verbal query.  If the CDI specialist accompanies the medical team, who is selecting the patients to be discussed, and the CDI staff can offer insight during interactive discussions of the patients, this is educational. 
 
I know it is a fine line, but the AHIMA document “Guidance for Clinical Documentation Improvement Programs” includes a section under verbal queries stating the following:
 
“For CDI professionals, not all verbal interactions with providers are queries . . . these are not considered verbal queries because the provider team determines which patients are discussed and the CDI professional is usually providing general education rather than addressing documentation issues.”
 
The underlying principle is that the provider should always be allowed to make his/her own conclusions regarding the appropriateness of a particular diagnosis in a particular patient’s record.  Please keep in mind that “leading” is a very subjective issue, which is why everyone would like clear guidance from CMS, and you are likely to get different opinions from each of five CDI “experts” in the same room.
 
Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, CDI Education Director for HCPro, Inc., in Danvers, MA, answered this question. Contact her at cericson@hcpro.com.



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