Although it has only been a few days since the poll question asking about verbal query policies was posted, 88 percent of the voters say that their facility's policy allows querying, but also requires the reason for query to be documented. So, if we assume that these policies require that everytime a query is asked verbally, the reason for query as well as the query itself is recorded in the CDI program records then the compliance, fraud and abuse issues that have been concerning the regulatory bodies and others about verbal queries is a non-issue. Here's the key.....the documentation and enforcement of the policy.
This may be a question for a future poll, but in my experience, just because we say that we have a policy to do XYZ, doesn't necessarily mean that the policy is carried out consistently. As with any other compliance concern, it is best to:
1. Document the policy and update it annually
2. Document the rationale or reason for the policy. In the case of verbal queries, making the reason for the policy part of the actual policy itself is probably a good idea. When you or others revisit the policy in a year or two, it is possible that the reason behind the policy was forgotten. When the reason is as important as it is in the case of verbal queries, it's best to include it.
3. Create and document the procedure to accompany the policy. Again, because of the important of this practice - documenting (a) the reason for a verbal query as well as (b) the fact that a verbal query was conducted and (c) how the physician responded, it is important to document how CDI staff will be performing all three of these activities.
4. Educate everyone about the policy and the procedure.
5. Consider reporting on verbal vs. written queries separately. Not only will this practice reinforce the importance of your verbal query policy and procedure, it can also give you some insight into what types of strategies are most successful (or not) in your organization
What does your verbal query poicy and procedure look like?
