A few days ago, I had my 6 monthly review of my performance as a hospitalist with my Medical Director. I was told that the number of queries I was sent in the last 6 months was very low. I answered all of them in less than 2 days. I was praised for this and it was probably due to the extensive CDI training I received as a physician advisor. This came up because it is one of the bonus metrics in our hospital.
Getting a lot of queries in the inbox does not necessarily mean that a particular doctor is a bad physician or a bad documenter. It just means that the doctors are more focused on improving the clinical condition of the patient than on documentation.
Majority of the hospitals have CDI programs to educate doctors on good documentation.
CDI programs are a must for educating physicians in good documentation. Good documentation reduces the number of queries. Some hospitals are using CDI scribes who are helping with educating the doctors while documenting in real time.
Proper documentation increases relative weight, expected mortality rate, expected LOS, CMI etc. along with accuracy of patients’ medical conditions which all in turn increase payment to the hospitals in the long run.
Like many things in hospital medicine, repeated reminders are needed to get things done as too many things are required to be done by hospitalists on a daily basis.
But, lot of other factors cause physicians unable to document everything they learn from CDI specialists so queries are inevitable.
What is the purpose of sending queries to doctors?
Answering queries has huge financial and quality impact for the hospitals. Queries improve CMI/Case Mix Index if missing CCs and MCCs are captured.
Queries sometimes remove some diagnoses which are documented without enough supporting evidence so payments and denials are not always related directly to volume of queries.
The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), found hospitals have incorrectly documented and/or coded severe malnutrition 86.5 percent of the time (173/200).
Why Queries are inevitable?
There is always a turnover for hospitalists. New doctors come and some experienced doctors leave.
Coding rules, Quality measures and Clinical definitions change with time. So, even experienced doctors need CDI education periodically and they also can miss documentation periodically. As you know Sepsis and Severe Malnutrition are under scrutiny recently. This may change to some other diagnoses in future.
Queries are probably here to stay despite the best CDI education and despite having all experienced doctors in a team.
Doctors usually focus on treatment of a patient rather than on documentation.
Why hospitalists do not document well consistently?
Hospitalists are very busy. Hospital Medicine work is intense. 7 straight days of 12hr shift work is tough.
With time, the complexity of the inpatients is going up. Patients are living longer and getting advanced medical treatments. Even when patients get admitted for simple things, hospitalists have to look into multiple complex medical issues of each admitted patient.
Patients’ census is very variable in hospital medicine. High patient load can make hospitalists unable to document completely.
One crashing or sick patient or a difficult admission early in the morning can put the entire day work upside down.
There are too many things asked of a hospitalist on any given work day. Meetings-administrative and family, huddles-morning and evening, grand rounds, etc.
Some doctors may even think that documenting and answering the queries is not relevant to the patient’s medical condition. However, answering those queries is very important for ICD 10 coding.
Does answering the queries help in reducing denials from insurance companies?
Commercial insurance companies like Medicare Advantage Organizations [MAO] are very well equipped to win the peer to peer reviews and appeals. Hospitals don’t have the required resources to fight them so they win by default in most Peer to Peer reviews and appeals.
MAOs deny inpatient status and some CCs and MCCs left and right. They have robust Peer to Peer reviewers if you try to appeal.
Answering queries which validate diagnoses like Sepsis, Severe Malnutrition will help Utilization Management nurses to get the denials by MAOs overturned resulting in appropriate payment for the services that you provide to patients.
Why do Hospitals spend so much time and money for CDI programs and send queries?
Hospitals have to make sure to get reimbursed appropriately and make sure doctors and other hospital staff get paid. Getting paid appropriately and on time is critical for hospitals to survive.
Queries are meant for the improving the accuracy, completeness, and integrity of the chart.
How to reduce the number of queries?
This should start with the education of medical students, residents, hospitalists, and all other staff involved in documention on patients’ charts. It should also involve healthcare leaders in the hospitals as they can look for ways to improve EMRs to help with better documentation.
Coding and Documentation specialists, Physician Advisors, Health care leaders, Utilization Management nurses, case management and quality should all come together and work for effective education to all those involved in documentation in the chart.
Hospitalists should work smarter not harder by learning better documentation techniques. Progress notes and discharge summaries should be just long enough to capture all the diagnoses with supporting evidence.
Avoid note bloat, copying and pasting without proper editing. If H&P and progress notes are long, it wastes everyone’s time and also important points about patient’s condition can be missed. It leads to burnout if everyone writes long notes wasting everyone’s time to read them.
If a hospitalist is getting a lot of queries it means that there is some work needed in learning the best practices of documentation. Too many queries can be one of the reasons contributing to burnout.
How to reduce the number of denials by insurance companies?
Every day, commercial insurance companies deny inpatient status and also deny payment for certain diagnoses like severe malnutrition and sepsis. Some of these are not justified. It is a common practice to deny inpatient status if patient does not stay through the 3rd midnight even though the patient already spent 2 mid-nights stay.
Of course, delays in doing procedures due to weekend or waiting for a consultants, placement issues, bad weather, no one available to take patient home are all the reasons patients can stay longer in hospital than anticipated. These delays should not count towards 2 midnight stay.
Higher denials can be payor specific e.g. AETNA, Amerihealth, Blue Cross etc. Payers like these get into contracts with hospitals that give the payer the upper hand in terms of combining admissions with similar diagnoses again and again e.g. Hyponatremia due to SIADH, Hepatic encephalopathy, etc.
To counter act all these issues, doctors have to realize that it is very important to document what is needed to prevent denials. Every progress notes from attending physician should contain the reason why patient needs to stay an other night. This helps the peer to peer reviewer/ physician advisor to do an effective P2P review and overturn the denial.
Try to do peer to peer reviews for as many denials as you can even if you think your chances of overturning a denial are minimal. You never know what can help you in overturning a denial. You also learn from the process.
While doing Peer to Peer review, prepare very well in advance to be able to do an effective peer to peer review.
Send upheld denials for appeals later if you believe you still have a case for overturning a denial. MA plans know that hospitals do not have much resources for this and they try to take advantage of this.
Look at initial anesthesia notes for surgical patients. They document ASA score which if equal to or more than 3, means patient has significant systemic health problems and might need longer stay than normal. Use this fact to argue while doing peer to peer reviews. Same way, age more than 75 years can also mean requirement for longer stay for surgical patients.
Now the main question: Should hospitalists answer all the queries?
Agreeing with a Query if appropriate and query completion rate on time can be one of the very important bonus metrics for hospitalists in hospital medicine.
Integrity and accuracy of every patient’s medical record is what we should strive to maintain as hospitalists. Answering queries does just that.
If hospitalists are not answering queries, hospitals should try to take measures to improve Physician engagement.
Document well so you get less queries; answer queries promptly so hospital gets paid appropriately for the work you do.
Delay in answering the queries will also increase the number of charts which are “discharged but not final billed”.