When I was on the task force that created AHIMA's white paper entitled, Managing an Effective Query Process, the issue of verbal queries created much heated debate. In the end, the white paper said only the following about verbal queries: "Verbal queries have become more common as a component of the concurrent query process. The desired result of a verbal query is documentation by the provider that supports the coding of a condition, diagnosis, or procedure. Therefore entities should develop specific policies to clearly address this practice and avoid potential compliance risks." Recently, I revisited the issue of verbal queries with a hospital and it brought back the memories of those heated debates.
In one discussion, it was suggested that the ideal scenario would be for hospitals to videotape all verbal queries. Imagine obtaining cooperation from physicians to be filmed during a query discussion, not to mention budgetary approval for the equiptment and the filming crew. Surely, we weren't suggesting that CDI specialists should be concurrently trained as filmmakers, were we? CMS' and the OIGs issue around verbal queries boils down to one simple concern: was the query a leading query? Or worse yet, are hospital CDI staff just telling the physicians what to document?
At one end of the spectrum, a hospital could implement a policy that all queries are verbal. In that case, if the queries are never documented, we never really know if the documentation in the patient's record is as a result of the physician's direct entry or, was the documentation preceeded by a query? In my experience, the likelihood of verbal queries not being recorded somewhere is quite low. For one thing, if we don't capture queries how will we know where physicians need follow up education? How will we be able to justify the CDI program's continued budget? And, how will we know what the CDI staff is doing with their time?
At the other end of the spectrum, a hospital could require that all queries be in written format. In that case, the number of queries will decrease, just because of the amount of time it takes to generate each query. Furthermore, physicians will be frustrated and less likely to cooperate with needing to read through each and every query - time for them is an even bigger issue.
The truth is somewhere in the middle. When physicians are accessible and willing, queries can be verbal. Otherwise, queries will be written - generally. In each case however, you will want to record the fact that a query was asked. These numbers are important for program statistics, physician education, and yes, even (or especially) for compliance purposes. Ultimately, we need to know that there was clinical evidence to support the asking of a query. Documenting that a verbal query was asked not only tags the record as one that the physician was queried about - but, should ensure that somewhere in that record is evidence - whether it's an abnormal test result, a consult or a medication order - to support the query that was asked.
This is a compliant process.....how do you manage your verbal query process? Answer the poll on the front page.....I'm hoping to get some good responses to the poll that will help all of our readers understand how others are managing this challenge.
