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.
Editor's note: The commentary in this article was originally presented in the HCPro, Inc., February 7 audio conference, "The Pediatric Medical Record: Opportunities for Documentation Improvement." Learn more about the audio conference at http://tinyurl.com/bbh9yl5.
Everyone knows that CCs and MCCs are under scrutiny these days. However, that doesn't mean hospitals should err on the side of caution when reporting these conditions. William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Fla., provides several tips that coders can employ to look for clinical evidence in the record before querying for these targeted conditions.
