Timing of a Physician Query

Timing of a Physician Query

by Chris Richards, RHIA, CCS

A physician query can be:

  • Concurrent
  • Retrospective
  • Post-bill

Concurrent:
A concurrent query is initiated while the patient is still in house; it occurs in real time and both encourages and enables more timely, accurate, and reliable responses.

Retrospective:
A retrospective query is initiated after the patient is discharged but prior to the bill being submitted. It is most effective in cases that have additional information available in the health record at the time of coding. It is useful in clarifying documentation related to short stays where concurrent reviews can not be fully completed. Additionally, there may be other unique circumstances that make concurrent queries impractical.

Post-bill:
Post-bill queries are most commonly initiated after the bill has been submitted. These types of queries are most often completed after an audit (internal or external).

A note on post-bill queries
Per regulation, a hospital has 60 days from the date it is initially paid to amend its bill. In the Medicare world, if the coding change results in the payment of a higher-weighted DRG assignment, 100% of such cases are selected by Medicare and reviewed for:

  • Correct DRG assignment, BUT ALSO:
  • Appropriateness of the inpatient admission
  • Quality of care rendered during the stay

The rebilling process is time consuming, expensive and inefficient. Additionally, if a pattern of frequent re-bills is detected, Medicare has the authority to investigate why the initial coding seems to be so inaccurate. It is a sort of a “Catch-22” for heavy re-billers.

Bottom line:
Keep these types of re-bill submissions to a minimum, as infrequent as possible. If you audit frequently for DRG accuracy, consider a pre-bill audit process that can be accomplished without delaying the initial bill, but can also prevent the hospital from becoming a red-flag outlier, subjecting itself to intensified review.

Next:
Some final thoughts

 

References:

  • AHIMA Practice Brief: Managing an Effective Query Process, 2008
  • AHIMA Practice Brief: Ensuring Legibility of Patient Records, 2003
  • AHIMA Practice Brief: Guidance for Clinical Documentation Improvement Programs, 2010

About the Author

Chris Richards, RHIA, CCS
Chris joined Barry Libman Inc. as a Senior Associate in 2014 after 27 years with Masspro, the Massachusetts Quality Improvement Organization (QIO). Chris’s areas of expertise include health information administration, case management, quality improvement, hospital payment oversight, and documentation education initiatives. He has a comprehensive understanding of the Federal Medicare program rules and regulations, as well as extensive experience ensuring that clinical coding and DRG assignment result in accurate provider reimbursement. A graduate of Hobart College, he received a postgraduate Bachelor of Science in Health Information Administration from Northeastern University.

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