The Essential CDI Guide to Provider Queries

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The Essential CDI Guide to Provider Queries

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The Essential CDI Guide to Provider Queries

Marion Kruse, BSN, RN, MBA
Jennifer Cavagnac, CCDS 

The Essential CDI Guide to Provider Queries is the authoritative source for defining policies, procedures, and best practices for provider queries.

Thanks to ICD-10-CM/PCS implementation, as well as the advancement of electronic health records and electronic query systems, CDI programs are being pushed in challenging new directions—requiring CDI specialists to redefine where and how they generate queries. Meanwhile, CDI program managers need innovative solutions to improve their query process, target high-risk diagnoses, and educate delinquent providers, coders, or CDI professionals.

The Essential CDI Guide to Provider Queries is the only resource that provides a comprehensive analysis of query guidelines and easy-to-follow strategies to improve your processes.

Using the tools provided in this vital guide, you can update your practices to meet the challenges of ICD-10-CM/PCS, government payer initiatives, auditor denials, and electronic initiatives.

With sample queries, policies, procedures, and national benchmarking data included, The Essential CDI Guide to Provider Queries is a valuable addition to your CDI library.

You’ll also find information on:

  • ICD-10 implementation
  • Recovery Auditors process
  • Electronic health records
  • Electronic query efforts
  • Compliance risks and OIG scrutiny

Table of Contents

  • Healthcare Reimbursement Initiatives 
    • Healthcare reimbursement: CMS and the IPPS 
    • MS-DRGs, CC/MCCs, APR-DRGs 
    • Value-based purchasing 
    • Patient Safety Indicators 
    • Outpatient payments 
  • Regulatory Environment 
    • False Claims Act 
    • Enforcement efforts: OIG, CERT, PEPPER, MAC, MIC 
    • Recovery Auditors and the audit process 
  • Coding Advancements 
    • Specificity requirements under ICD-10 
    • Incorporating coding regulations into query efforts 
  • Query Guidance Progression 
    • CMS 
    • AHIMA publications 
    • Joint guidance 
    • ACDIS publications: Code of Ethics, EHRs, staffing, etc. 
  • The Query Process 
    • Developing facility/systemwide policies and procedures 
    • How to review the record 
      • Principal and secondary diagnoses 
      • Unspecified diagnoses 
      • Diagnosis sequencing 
      • Clinical indicators 
    • Physician judgment and leading queries 
    • Query types 
      • Verbal vs. non-verbal 
      • Open ended 
      • Multiple choice 
      • Yes/no queries 
      • Queries as a permanent part of the medical record 
  • Electronic Health Records and the Advancement of eQueries 
    • The problem with the problem list 
    • Establishing effective eQuery etiquette 
    • Balancing eQuery efforts with on-site physician education and engagement 
  • 7. Query Assessments, Program Auditing, and Education Opportunities 
    •  Productivity measures 
    • Agree rates 
    • Ratios and data analysis over time 
    • Program targets: Case-mix index, CC/MCC capture rates, etc. 
    • Quality measures 
    • Physician engagement measures 
    • CDI specialist educational opportunities 
    • Coding/CDI collaboration efforts 
    • Retrospective and prospective audits for effectiveness

Bonus Tools

Sample query policies and procedures, sample processes for eQuery review, sample DRG reconciliation process, sample queries for common ICD-10-CM/PCS difficulties, sample queries related to recent query practice recommendations in Guidelines for Achieving a Compliant Query Practice.

Who Should Read This?

  • Clinical documentation Improvement manager/director
  • Clinical documentation integrity manager/director
  • HIM manager/director
  • Case management manager/director
  • Director of revenue Cycle
  • CDI specialist
  • Quality manager

About the Authors

Marion Kruse, BSN, RN, MBA, is an expert in Medicare regulations who provides education on project management and process improvement, targeting various severity-adjusted DRG systems. Kruse has implemented CDI programs for both small and large hospital systems and is an AHIMA-approved ICD-10 trainer. She has worked for a number of consulting firms throughout the country.

Jennifer Cavagnac, CCDS, is assistant director of CDI at Baystate Health, a four-facility integrated healthcare system and major teaching hospital based in western Massachusetts.

Published May 2016