Update for Compliant Queries Reveals Concern for Potential Fraudulent Upcoding

The updated guidelines, developed jointly by AHIMA and ACDIS, are expected to be announced today.

The American Health Information Management Association (AHIMA) is expected to release today the highly anticipated and long-awaited preliminary update to guidelines for achieving a compliant query. Earlier today, the Association of Clinical Documentation Integrity Specialists (ACDIS), released the guidelines which had been a collaboration between the two associations.

As one of the four ICD-10-CM/PCS Cooperating Parties, along with American Hospital Association (AHA), the Centers for Medicare & Medicaid Services (CMS), and the National Center for Health Statistics, the 2001 AHIMA’s brief and its subsequent updates in 2008, 2013, 2016, and 2019 have been deemed “industry standards” quoted by government attorneys addressing allegations of fraudulent “upcoding.”   

As an example, in the case of the United States of America ex rel., Ronda Osinek, versus Kaiser Permanente, the government alleges that “Kaiser regularly brought these mined diagnoses to the physician’s attention for addition to the patient’s medical record using a tool called a “query”—which in the healthcare industry is a communication tool used to clarify documentation in the health record. Queries present significant risks for improper diagnosis coding, and national standards guide and limit queries’ use.  The standards include that a query cannot be leading (i.e., cannot direct a provider to a specific diagnosis) and cannot discuss financial impact. But Kaiser routinely violated the national query standards and used queries not to clarify medical records, but instead to press physicians to retrospectively add new diagnoses via addenda that had nothing to do with the visit, so that Kaiser could then seek payment from CMS for these diagnoses.”  The full text of the government’s allegations is available at https://www.justice.gov/opa/press-release/file/1444936/download

Ronald Hirsch, MD, said in an email, “leading queries are at the foundation of the Kaiser Health qui tam suit that alleges that ‘Kaiser regularly brought these minded diagnoses to the physician’s attention for addition to the patient’s medical record.’”

The 2022 proposed version released today (Oct. 10) will not take effect until all feedback has been received and a final version is published later.  Comments are due on Oct. 25, 2022, and may be submitted through mechanisms announced by AHIMA and ACDIS. 

Programming note: Listen to Talk Ten Tuesdays tomorrow, Oct. 11, at 10 Eastern when Melissa Potts, an AHIMA representative, will report on the new guidelines.


Chuck Buck

Chuck Buck is the publisher of RACmonitor and is the program host and executive producer of Monitor Monday.

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