CDI Queries: Why Must They be Compliant?

A CDIS recently posed a question that baffled – to say the least.

In my consulting practice, I often review provider documentation to identify documentation gaps and to direct my educational efforts. I also get a significant amount of information about the state of the facility’s clinical documentation integrity process. This informs my advice on how to establish or revamp or reinvigorate a clinical documentation integrity (CDI) program.

Recently, I was doing a project for a small hospital that has coders performing as de facto clinical documentation integrity specialists (CDISs), and they were not using a formal query process. I expressed concerns that the CDI inquiries, as they were being done (verbally, concurrently, and recorded in an email without multiple choices), were not compliant. Someone innocently posed the question, “why do queries have to be compliant?” This stopped me dead in my tracks.

It reminded me of a day in 1998. My now-almost 24-year-old son was an extremely obedient child. If he got out of line, my husband or I would count a warning. On that fateful day when Scott was five years old, I counted “one…two…two and a half…two and three-quarters…THREE.” I sank down on the steps, looked at my husband, and pondered, “what do we do now?!” I had never gotten to three before, and had really never considered what the consequences would or should be.

In medicine, I always accepted that we had to be “compliant.” My lawyer/doctor friend, John Irwin, who we had on Talk-Ten-Tuesdays a few weeks ago, often shares lots of horror stories about noncompliant professional billing getting folks into dire legal consequences due to upcoding.

The term “compliance,” as it relates to healthcare, used to confuse me. I think the most useful Merriam-Webster definition is “cooperation promoted by official or legal authority or conforming to official or legal norms.” In healthcare, we need to comply with the governmental rules and regulations, or else we can be targeted and audited, have to give money back, or even go to the extreme of being criminally prosecuted for intentional fraud.

Where does it say that queries must be compliant? I started with the American Health Information Management Association’s (AHIMA’s) Ethical Standards for CDI Professionals, revised in 2016. It states that CDI activities should promote “accurate, complete, and consistent clinical documentation” “in accordance with regulatory and documentation standards and requirements, as well as all applicable official coding conventions, rules, and guidelines.” It goes on to specify that one should “never participate in (or) conceal unethical reporting practices, or support documentation practices intended to inappropriately increase payment, qualify for insurance policy coverage, or distort data by means that do not comply with federal and state statutes, regulations, and official coding rules and guidelines.” Finally, it asserts that a CDI professional who is aware of unethical, noncompliant, or unlawful activity should report it to the organization’s compliance officer.

AHIMA’s CDI Toolkit from 2016 explains that it is at the discretion of a third-party auditor, be it a Recovery Audit Contractor (RAC), U.S. Department of Health and Human Services Office of Inspector General (HHS OIG), Quality Improvement Organization (QIO), etc., to determine whether a query will be accepted as being supportive of a claim billed. I made the leap that these are the folks who could hold us to the standard of compliance. It had me conclude that if we lead a provider to give us a comorbid condition (CC) or major comorbid condition (MCC) diagnosis that could increase reimbursement by affecting the diagnosis-related group (DRG), especially if we do it as a pattern, there could be serious repercussions. Intent is what transforms an error into fraud.

In my search for a definitive response to this question, rather than my intuitive answer, I found some literature authored by Andrew Rothschild, MD, MS, MPH, FAAP. The first was a presentation from AHIMA 2009 titled Writing Successful Physician Queries. I also found an article in the Report on Medicare Compliance, Volume 18, Number 43, published December 2009, which spoke to the concept of queries being both compliant and efficacious. Chuck Buck and I were delighted when “The Document Doctor” agreed to be our guest on the Talk-Ten-Tuesday broadcast of Nov. 7, 2017.

In preparation, last week we ran a poll:

Has your hospital or system ever gotten in trouble for noncompliant queries?

1. Yes, as a pattern, with serious consequences (large payback, fraud prosecution): 1 percent
2. Yes, for a single/limited case/s, with consequences of monetary takeback: 2 percent
3. Yes, for a single/limited case/s, with follow-up targeted audit: 1 percent
4. Yes, other outcome: 3 percent
5. No, noncompliant query noted, but no consequences: 10 percent
6. No (we don’t do noncompliant queries, or we have never been caught!): 38 percent
7. Not applicable: 41 percent

I disregarded the 41 percent, for whom the question was not applicable. Twelve percent of our listeners for whom the poll was applicable had experienced consequences from noncompliant queries. Seventeen percent had had noncompliant queries discovered without significant consequence. I’m sorry I can’t provide you with more details to comprehend the extent of these infractions or the seriousness of the consequences.

Queries are performed to make sure documentation accurately depicts patient encounters. Why do we have to do compliant queries? The answer is not the same as my answer to Scott – because I said so. It’s because the government says so. Our guidelines and rules say so.

And because it is the right thing to do.