Q&A: Retaining queries in the medical record
Q: Our facility does not retain written queries in the medical record, but I’ve heard that other hospitals do. Is this something we should consider?
A: The issue of whether to retain written queries as a permanent part of the medical record (or whether to retain them at all) has been a matter of some controversy among compliance officers and hospital attorneys. The ACDIS/AHIMA physician query practice brief encourages facilities to craft policies around this matter.
Some believe that making queries part of the medical record creates an unnecessary liability and can open the facility to recovery auditor vulnerabilities. Others believe that query forms/programs should be transparent and used to defend against Recovery Auditor and OIG scrutiny.
If the queries are not part of the permanent medical record, define how the forms will be retained and where and how they will be accessed when needed. The 2008 AHIMA query practice brief “Managing an Effective Query Practice” calls on facilities to address the permanence and retention of the completed query form. It recommends that programs refer to applicable state guidelines to ensure compliance.
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.