The road to ICD-10 has been a long one, and we still have many miles ahead of us. Organizations have invested a significant amount of time and money into this venture, and even though October 1 is rapidly approaching, there’s still work to be done before and after implementation.
The U.S. healthcare system is and will continue to be dependent on clinical codes and is thus equally dependent on accurate and complete clinical documentation.
Coding for sepsis is often easier said than done. Obstacles range from difficulty distinguishing between documentation for sepsis and related conditions to trouble with physician queries.
Chasing down information on incomplete records can be overwhelming and a lost cause. What do you do when a medical record is incomplete 30 days after discharge (or 14 in California's case) and thus does not meet regulatory standards? Do you file it away without an answer to an open query or a signature from the practitioner? What if the responsible practitioner retired, expired, or is no longer practicing at your facility? Are you doing everything you can to get most deficiencies completed prior to the patient being discharged?
At the Association of Clinical Documentation Improvement Specialists (ACDIS), questions on physician queries are never few and far between. Although AHIMA has published a couple briefs on the topic over the last decade, questions have still remained about how to implement a compliant and effective query process.
Editor's note: Medical Records Briefing (MRB) catches up this month with Monica Pappas, RHIA, president of MPA Consulting in Long Beach, Calif., and an MRB advisory board member, to discuss physician queries.
