Guidance on a Compliant Query: Internal Escalation Policy

In February 2013, the practice brief on “Guidance on a Compliant Query” was published in the Journal of AHIMA. The intent of this practice brief is to maintain the integrity of the coded healthcare data. The purpose of the query process outlined is to ensure appropriate documentation appears in the health record. Additional policies may need to be implemented when questions arise regarding the clinical validity in practitioner documentation.

The AHIMA-developed Internal Escalation Policy includes sample policies that require a CDI specialist or coder to escalate issues regarding clinical documentation validity to a manager or steering committee. One example of an escalation policy would route these types of cases to the manager of coding or CDI. It would be the responsibility of the coder or CDI specialist to refer any clinical validity questions to their manager, who would then determine if the case would need to be referred to an appropriate administrative representative. In another example, a multi-disciplinary committee would be implemented and tasked with reviewing the cases in which clinical validity of documentation is in question. This committee would be responsible for providing guidance and next steps depending on each case reviewed.

The below Internal Escalation Policy is to be viewed as guidance only and not a mandatory practice unless the facility or entity institutes such a policy.

 

Internal Escalation Policy

When the question of clinical validity is identified in practitioner documentation, the facility may wish to follow their internal escalation policy rather than requiring the CDI specialist/coder to query the practitioner. Sample escalation polices are outlined below.

 

Sample 1

When the question of clinical validity is found in practitioner documentation, the case should first be referred to the CDI manager/coding manager for review.

a.  The CDI manager/coding manager determines if the case should be referred to the appropriate administrative representative (whether a physician advisor/physician champion, CPO, VPMA, Medical Director, corporate compliance officer or designated designee) for further review.

  • i.  The administrative representative notifies CDI manager/coding manager of their concurrence with practitioner.
  • ii.  The administrative representative does not agree with the existing documentation and discusses the case with the practitioner. The practitioner provides clarifying documentation when indicated.
  • iii.  If significant disagreement cannot be resolved by the administrative representative, the case escalates to the appropriate medical staff or administrative physician leader for further review.

b.  Steps in the escalation process are tracked for internal compliance purposes, such as in a query tracking log, or CDI worksheet/internal coding worksheet communication.

 

Sample 2

An organization may wish to implement a multi-disciplinary committee (consisting of physicians, quality, compliance, and HIM staff) to review cases submitted by CDI and coding when diagnoses are inconsistent with the patient’s clinical picture, or the clinical picture is inconsistent with the diagnoses. The committee can provide guidance on the best course of action on a case-by-case basis.

 

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