An Added Bonus: The Physician Query
One additional issue that has remained central to CDI programs since their inception is the physician query. A physician query process involves asking a physician for additional clarification on a patient's diagnosis. However, throughout the years the opinion has been held that too many physician queries involve "leading questions" which may sway the physician's decision one way or the other, according to Spryszak. The definition of "leading" has been the subject of much dispute.
As a result, the American Health Information Management Association (AHIMA) published Guidance for Clinical Documentation Programs to help outline what would constitute a "leading query" versus a compliant query.
Spryszak refers back to the example of sepsis vs. urosepsis to provide an example of the physician query's impact on both the CDI program and facilities' vulnerability to RACS.
"If a higher than normal percentage of patients in a facility are being coded to sepsis instead of just a urinary tract infection, it may be because the processes involved," she says. "A review of these cases may show that the final DRG assignments were the result of asking leading questions."
When it comes to RAC audits and denials, every part of the process matters; but when you have a thorough, compliance-based CDI program in place, it puts a facility in that much better of a position to defend against them.