Monday, July 13, 2009

Coding Mgr Handbook: Ch 4 Queries & POA

Chapter 4: The query process & POA (Present on Admission)

** Coder queries
** Present on Admission

As a coding manager, you will have times when you or your coders just can’t figure out what the physician has documented, or is recommending for a code. When these occasions happen, you need to initiate a coder inquiry. Querying the physician can vary from being a very informal process to a formal process that becomes a part of the patient’s medical record. This clarification for documentation issues may include issues such as diagnoses, procedures, medications, clinical lab or x-ray findings. The ultimate goal of the query process is to educate the physician and help them document more clearly into the record, so that query’s become few and far between.

When querying a physician a standardized query form should be used. As the coding manager, you should look at the different types of coder query form, and develop one that works well for you and your department. You may have to develop different forms for different situations. You may want to consider a query form for “office” and another for “hospital” type queries. CMS recognizes the usage of physician queries and offers guidance upon when they should/should not be used. In a memo put out by the Health & Human Services department back in 2001, they set policy that determined that query forms are to be primarily used as a communication tool within the hospital. They also go on to state that HHS defers to the HIM experts and organizations to allow the usage of these documents provided they address clarification of medical record documentation that is not already contained within the medical record

So, all queries should be used to clarify clinical and procedural documentation in addition to data quality issues. Reimbursement issues can be queried too, but you should be querying to understand the physician’s basis for what was documented, not trying to addendum or query simply to increase reimbursement or revenue processes.

I encourage the use of query forms, but they should be monitored. The query process should include feedback from the physicians as to how they like being queried. Do they prefer to receive the query from the coder, or from you, the manager? Get buy-in from the providers, and design your query form around their expectations and feedback. You want to make the form convenient for the provider, yet give you good data so you can code the encounter correctly. Common sense should be used in the query process. Don’t write queries on sticky notes, scrap papers or anything that can be easily lost, removed or discarded. You want to preserve the integrity of the query process. Always use a designated query form when possible.

When monitoring your queries, also keep track of the query usage by the coder and physician. You should monitor and keep a trend report on query usage by physician and by coder, positive and negative responses, query content, such as diagnostic information missing, or DRG information. Review each of the queries for content and if they are truly appropriate in terms of documentation enhancement. Be on the lookout for questions, or concerns that are leading or are guiding the provider to a specific outcome in documentation. Always review the legibility of the record documentation. If you can’t read it, you can be assured any type of an auditor or audit process will not include documentation if it is not legible. If you are seeing specific trending, act upon it and make adjustments as needed in your query process.

Also, keep a copy of all queries that are sent. Send the original form to the provider, but keep a copy. You may find it easier to keep an electronic copy in a specific data file, and then print out a paper copy to go to the physician. When the query is sent back with the physician clarifications, you will need to file that in the medical record (or appropriate area). Once the completed query is received back, you may want to scan or photocopy the completed and signed form into an electronic database in addition to filing within the medical record. If you or your facility does not allow the query form to be a part of the medical record, indicate on the coding summary or appropriate area in the chart that a query was made, is available, and is located in this specified area. Your compliance or risk management department may be able to help you out with formalizing the file process for completed queries. Keep in mind that the use of a query should not replace face to face interaction with the provider if needed. There will be occasions when you should meet and discuss documentation issues and concerns directly with the provider.

As the coding manager, you should educate and instruct both your coders and the physicians regarding the criteria for when an official query will be initiated. AHIMA has set for very specific guidelines upon when to query a physician as denoted in their publication Managing an Effective Query Process [AHIMA. "Managing an Effective Query Process" Journal of AHIMA 79, no.10 (October 2008): 83-88.]

It is extremely important that the coder verify that the entire record has been examined thoroughly before initiating the query process. A good practice would be to have the initiating coder review the record, then have a second set of eyes review it again to make sure they really didn’t miss the information. That second set of eyes could be another coding peer, co-worker, or even you as the manager. You want to avoid unnecessary queries to the physician, but also ascertain if it is truly warranted. It is inappropriate for a coder to query a provider for an insignificant matter, or clinical issue. Educate, Educate, Educate all your coders and physicians on this query process. Remember, the MAIN REASON for the query process is to ultimately make provider documentation in the record better for all.

There are numerous reasons why a query should be initiated. These really are common sense reasons. Ensure that you, your coding staff and physicians thoroughly understand what is lacking in the documentation, and why the query was initiated. These reasons (though not all inclusive) include

 There are clinical indicators in the record, but the physician does not specifically document the diagnosis or condition relevant to the patient at that time.

 The clinical indicators denote more specificity than what the physician has denoted

 Cause and effect relationships are present but not documented as such. (i.e. somnolence secondary to initiation of IV therapy for seizure disorder)

 The provider has neglected to determine the underlying cause of the symptoms, or has not clearly defined a diagnosis for the symptoms manifested with this visit or stay.

 The provider documents and initiates treatment for symptoms, but has not documented a working diagnosis

 Documentation regarding reportable conditions or procedures is conflicting, ambiguous, or is otherwise incomplete

 Abnormal diagnostic test results indicate the possible addition of a secondary diagnosis or higher specificity of an already documented condition.

 The patient is receiving treatment for a condition that has not been documented

 Abnormal operative/procedural findings not documented

 It is unclear as to whether a condition was ruled out

 The principal diagnosis (the reason, after study, for admission) is not clearly identified

 Pre-determined and agreed upon (with medical staff) clinical criteria are met

 If multiple questions need asked on a specific encounter/stay, clearly spell this out to the physician, so all questions get responded to with the same query.

Query forms should not lead, imply or direct the provider in any way toward a specific or specified response. The forms should also avoid any implication of a financial effect for the facility or practice. AHIMA allows forms that contain multiple-choice questions and answers, provided that the coder is the clinically possible choices with the addition of a blank area denoted as “other” in which the provider can enter his own notation. I do not like having multi-choice answers on the query forms; I feel that just sets you up as a manager for more pointed review for risk management, and compliance issues.

If you are a manager that has a clinical documentation specialist (CDI) you may want them to be your query liaison for coding queries or documentation concerns. A CDI is specifically trained and educated to review documentation protocol and clarify obscure, incomplete, or inaccurate notations within the medical record. They truly are the “experts” in the query process. However, if you have to initiate the query process on your own or with your current coding staff following the above criteria should always guide you as to when you should/should not query. Consider developing a flow chart as to when you should/should not query the physician. Flow charts can simplify the decision making processes for when to query.

As a coder, you have 3 separate timeframes as to when the query process may be appropriate. You may want to initiate your query as a concurrent query. Concurrent queries are made during the time that the patient is still on-site at the facility. This is the timeliest way to query, and the most accurate. It also enables the providers of care to make any needed changes during the time of stay, which is always more appropriate, than when the patient has been discharged, or is no longer on-site. The problem with this scenario is coders rarely get the chart during a concurrent time-frame to begin the coding processes. (Refer to the above bulleted listing as to possible issues to clarify if you are able to perform a concurrent query.)

The most common time scenario of a query process is the retrospective query. This happens once the patient has been discharged, or is no longer on site at the facility. This enables the coder to query and correct documentation errors prior to submitting a bill to the patient or a 3rd party payer. This is very effective when additional information is needed such as pathology and laboratory reports that are considered “final”. The “final” ancillary services reports are nearly always added to the record post patient discharge. Consider these options for when to query as a retrospective analysis:

 documentation is vague, inconsistent and/or ambiguous, unclear, incomplete, unspecified or general in nature

 principal diagnosis (reason for admission, after study) is not clearly identified

 abnormal diagnostic test results indicate the possibility of a secondary diagnosis or shows increased specificity of an already documented condition

 Ambiguity as to whether a condition has been ruled out or worked up

 patient is receiving treatment for a condition that has not been documented

 significance of abnormal operative/procedural/pathologic findings are not documented

 pre-determined and agreed upon (with medical staff) clinical criteria are met to be queried upon

 agreement and documentation of diagnoses documented by other health care providers such as, Nutrition Services, Respiratory Therapy, Physical or Occupational Therapy, Wound Care Team, Discharge Planning,

Querying a physician after the billing has been submitted should never be done for financial or revenue related reasons. These types of queries should only be done for internal auditing and documentation education purposes. If you find a glaring documentation error, after the billing process has been initiated, you should amend the record, and amend the billing process. However, you should clearly document why the amending of the record is necessary. You should also initiate any financial monies to be refunded immediate, and submit a corrected claim with all the documentation supporting the corrected claim, the information regarding the refund, and how the correct claim should be processed.

The query process can seem cumbersome and redundant. It may also seem that it slows down the revenue processes. Reality is bear out, that correct billing the first time through, is always more cost effective than having to do appeals, or amendments to your claims.

Queries do provide an outlet for education for physicians and coders. Documentation is crucial to patient care, and not only is documentation crucial, but being able to paint the picture of quality care is probably the most important aspect ever. Your query process should always be able to:

a) enhance medically necessary record documentation,
b) provide an outlet for clarification and understanding of the regulations and requirements for reimbursements by 3rd party payers

c) correctly analyze clinical data and it’s application on the care of the patient,
d) enhance communication skills with providers and other clinical staff involved in patient care
e) Provide a complete picture of the scope of care given to the patient during their hospitalization or procedural care setting as a rationalization of the medical necessity across the continuum of care...


What is present on admission (POA)? As of October 1, 2007 IPPS (Inpatient Prospective Payment System) hospitals are now required to identify secondary diagnoses that are present upon the admission of the patient to the facility. The purpose of POA is to differentiate between diagnoses present at the admission and conditions or diagnoses that develop in the patient during and admission or long-term stay. Only IPPS hospitals are required to report POA, the following hospitals listed are exempt from the POA requirements:
 Critical access Hospitals (CAH’s)
 Long-Term Care Hospitals (LTCH’s)
 Maryland Waiver Hospitals
 Cancer Hospitals
 Children’s Inpatient facilities
 Inpatient Rehabilitation Facilities (IRF’s)
 Psychiatric Hospitals

CMS implemented a phased in approach for the POA requirements. Although hospitals began reporting POA information on 10/2/2007, as of April 1, 2008 hospitals are now required to report a valid POA code for each diagnosis on a claim. If the claim does not include a valid POA code, it will be returned and not processed further until re-submitted with the correct information attached.

CMS has implemented general reporting requirements for POA.

 The POA indicated is required for all claims involving Medicare inpatient admissions to general acute care hospitals
 POA is defined as present at the time of the order for the inpatient admission. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery are considered POA.

 A POA indicator is assigned to principle and secondary diagnoses as denoted in the ICD 9-CM official guidelines for coding and reporting.

 Issues related to inconsistent, missing, conflicting or unclear documentation must be resolved by the provider.

 If a condition would not be coded and reported as based on the UHDDS definitions and current official coding guidelines, then the POA indicator would not be reported.

 CMS does not require a POA indicator for the external cause of injury code unless it’s being reported as an “other diagnoses”
Of course, POA brings up some complex documentation issues as far as POA reporting and querying. POA queries should follow the normal standard Query protocols, as I discussed earlier in the chapter. But physicians and providers are creatures of habit, so documentation in the charts take on a similar look and feel from the providers, regardless of what diagnosis or symptoms they are working up and treating. As a coding manager, (and educator) we need to be proactive and meet with these providers and help them choose and document POA effectively in the chart. They may need help ascertaining what codes really should be POA vs. what is an illness or symptom that developed post-admission. We really need to step up and help educate our providers to feel comfortable in their knowledge of the POA process and how they fit into that process.

Unfortunately, for the physician/provider they are the one held responsible for documenting POA upon admissions to the hospital. The coder is responsible for discovering if POA is denoted. If it is inconsistent, missing, conflicting or unclear, the provider must then be queried. Many hospitals have developed a separate query form strictly for POA issues.

A separate query form for POA helps the physician recognize that this is not your “standard” query, but one that truly has immediate revenue implications. If the POA data is not correctly noted on the UB form, the claim will automatically be returned from CMS and other 3rd party payers.

This means that they have not even looked at your claim. In some cases, if you are using a clearing house for your claims submission, these incorrect claims will not even get through to CMS before being returned back to the facility! If this happens, you’ve now slowed your revenue stream… and of course our goal, as managers, is to keep that revenue flowing smoothly. You don’t want your revenue coming in erratically.

As we work through this POA process we should make sure that we have clearly written policies and protocols for our staff and providers to follow. We need to educate on a continuing basis. Don’t think that the 1-time meeting over lunch will suffice. We need to keep the topic at the forefront, and go over and over the criteria that needs met. With any habit, it takes a minimum of 6 weeks to break a bad one. So think of how hard it is to start a new habit of documentation which encompasses the POA information. Providers really do have a difficult time with this, as they have an established, habit of how they document, so these changes, no matter how subtle, are HUGE to them. We need to support our providers with the essential feedback for their documentation of POA both positive and negative. To do that, track the monitoring progress of POA claims both concurrent and retrospective audits utilizing a case mix sample or focus on those high-risk or problem areas. Look at identified problem areas such as acute vs. / chronic conditions, combination codes, and rule-out diagnoses. The best and quickest indicator of a POA problem is if you are getting your claims returned before they’re even processed by the carrier!!!
Starting with discharges on October 1, 2008, the DRG assigned to a discharge with specifically identified diagnosis codes will be assigned a DRG that does not result in higher payments based on the presence of the secondary diagnosis code(s). What this means is that hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. Therefore, the claim would be paid as if the secondary diagnosis was not present. CMS developed and included on their web site at This reference/fact sheet can be downloaded or viewed. I’ve also included this table (below) that shows examples how this POA indicator can affect your revenue if not included or intentionally (or unintentionally) left off the claim. I’ve also included the definitions and acronyms of some of the verbiage that you will encounter on the CMS/HHS website.

CMS POA Indicator Options and Definitions
HAC = Hospital Acquired Condition
POA = Present on Admission
CC = Complication & Co-morbidity
MCC = Major Complication & Co-morbidity
DRG = Diagnosis Related Grouper
Code Reason for Code
Y Diagnosis was present at time of inpatient admission.
CMS will pay the CC/MCC DRG for those selected HACs that are coded as "Y" for the POA Indicator.
N Diagnosis was not present at time of inpatient admission.
CMS will not pay the CC/MCC DRG for those selected HACs that are coded as "N" for the POA Indicator.
U Documentation insufficient to determine if the condition was present at the time of inpatient admission.
CMS will not pay the CC/MCC DRG for those selected HACs that are coded as "U" for the POA Indicator.
W Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission.
CMS will pay the CC/MCC DRG for those selected HACs that are coded as "W" for the POA Indicator.
1 Unreported/Not used. Exempt from POA reporting. This code is equivalent to a blank on the UB-04, however; it was determined that blanks are undesirable when submitting this data via the 4010A.
CMS will not pay the CC/MCC DRG for those selected HACs that are coded as "1" for the POA Indicator. The "1" POA Indicator should not be applied to any codes on the HAC list. For a complete list of codes on the POA exempt list, see page 110 of the Official Coding Guidelines for ICD-9-CM.

If you are still curious, the motive behind the POA secondary diagnosis reporting is due to CMS/HHS commitment to improving the quality of care, and to encourage physicians to provide medically necessary quality care in our hospital systems. This goes hand in hand with Medicare’s directive that payment shall be made for those items and services that they have deemed as reasonable and necessary. Medicare is encouraging the use of POA reporting, as they want to see a reduction in hospital acquired conditions that they ultimately have to pay for. These HAC’s have been identified as diagnoses such as infection, bed sores, fractures, and even clinical care errors such as wrong medication, or wrong dosage administered, surgery performed on the incorrect body part. Medicare has compiled a listing of these HAC’s that are reasonably preventable. Medicare will pay for the physician and the care of the HAC including critical care or acute care for that condition. However, they want to be able to report if this additional payment for an HAC service could have been avoided if the patient’s initial POA illness were clearly documented and separately identifiable from a HAC. The list below outlines only a few of the diagnoses/items that Medicare deems as a HAC.

• Foreign object (such as a sponge or needle) inadvertently left in patients after surgery
• Air embolism - an air bubble that enters the blood stream and can obstruct the flow of blood to the brain and vital organs
• Transfusion with the wrong type of blood
• Severe pressure ulcers – deterioration of the skin, due to the patient staying in one position too long, that has progressed to the point that tissue under the skin is affected (Stage III), or that has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints (Stage IV)
• Falls and trauma:
• Fractures
• Joint dislocation
• Head injury
• Crushing injury
• Burn
• Electric shock
• Catheter-associated urinary tract infection (UTI)
• Vascular catheter-associated infection
• Manifestations of poor control of blood sugar levels
• Surgical site infection following coronary artery bypass graft (CABG)
• Surgical site infection following certain orthopedic procedures
• Surgical site infection following bariatric surgery for obesity
• Deep vein thrombosis (a blood clot in a major vein)
• Pulmonary embolism (blockage in the lungs) following certain orthopedic procedures

Since POA is still in its infancy, currently we have little data to see what the outcomes will be for CMS and 3rd party payers upon the quality of inpatient care within the system. However, as we continue to report and track our hospital POA’s we will be contributing to the long-term success or failure of this initiative. In the interim, we need to continue the cycle of identifying the POA’s and improving our documentation of a POA vs. / a HAC and getting the correct conditions reported via our UB-04’s. Then to cap it all off, we should be reimbursed for those diagnoses that need care as a POA, and ultimately reduce and lower the HAC’s.

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