Q&A: Determining an appropriate query percentage

Q: Providers at our facility believe the coding and clinical documentation improvement departments send too many queries. What's an appropriate percentage for us to be sending? 

A: Most new programs have a query percentage benchmark of 30%-40%. Basically, this means that every 100 reviews should yield query opportunities 30% of the time. This is a broad guideline—sometimes five reviews yield no opportunities for clarification, and sometimes five reviews yield five opportunities. This performance measure shouldn’t be applied to individual reviewers but to the program overall because more opportunities exist with records from medical or surgical units, for example, than with pediatric or obstetric units.

This measurement should shift over time as well. Theoretically, physicians will learn to document acute on chronic systolic heart failure and the type of pneumonia, thereby decreasing the need for queries. 

To draft reasonable expectations for the percent of queries expected, conduct annual coding audits aimed at uncovering additional documentation opportunities, and chart the percentage of those records that contain those opportunities. For example, out of 100 records, an additional severity of illness measure could have been captured in 35 of them. Reset your query expectations for these measures, educate staff and physicians of the reason for the expansion, and then readjust the query expectation rate for the program and that particular measure.

Editor’s note: This question was adapted from the HCPro book The Coder's Guide to Physician Queries by Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, with contributions from Rose T. Dunn, MBA, RHIA, CPA, CHPS, FACHE.

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