Q&A: Creating a retrospective query process

Q: Who should be responsible for coordinating the retrospective query process in a hospital? 

A: Facility administrators need to make several decisions related to the retrospective query process and chart reconciliation. They must collaboratively choose which department owns the retrospective query process or decide whether the process of performing the retrospective query should be divided up based on particular circumstances.

For example, the CDI staff may be responsible for obtaining a query answer retrospectively when the physician did not answer the query they issued prior to discharge. Alternatively, HIM may be responsible for obtaining answers related to present-on-admission issues or cases not reviewed concurrently by the CDI staff. Other determinations include the following:

• The role of HIM in conducting retrospective queries related to clinical information introduced after the chart was last reviewed by the CDI specialist
• Which department will work with physicians to obtain missing documentation from discharge summaries that was present in the progress notes during the course of the stay
• How long to hold a patient’s chart when awaiting the physician’s response to a query, if the query will affect DRG assignment
• How long to hold a patient’s chart when awaiting a physician’s response to a severity of illness query that does not influence the DRG assignment

Retrospective queries should be completed as soon as possible postdischarge prior to billing, but definitely within seven days of discharge, so that the query may be answered and the medical record completed within the 14- to 30-day deadlines established by states, CMS, and The Joint Commission. Although there are no official timelines for correcting a record, the moment a notice from an attorney, Recovery Auditor, or OIG official is received is not the time to add an addendum, clarification, or late entry. 

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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