Administrative Memos

200103

FROM: Theodore O. Will, Chief Executive Officer
DATE: Mar 14, 2001
SUBJECT: Clarification in Regard to DRG Validation and the Use of Physician Query Forms by Hospital Information Management Personnel
IPRO CONTACTS:

Renato Estrella, RHIA, Administrator, HIM, ext 261
Cesar Limjoco, MD, CCS, Sr. Director, HIM/PEPP ext 261

IPRO recently received clarification from the Health Care Financing Administration (HCFA) in regard to Coding/DRG validation review and hospital use of boilerplate coding summary forms (e.g., physician query forms). The use of physician query forms is not an acceptable substitute for physician documentation in the medical record.

Physician query forms are increasingly being used by hospital coders to communicate with physicians in order to obtain clarification on conflicting, incomplete, or ambiguous documentation in the medical record. Hospitals have requested that these query forms be accepted as substitutes for physician documentation in the medical record in response to IPRO inquiries after Medicare/ Medicaid Coding/DRG validation review. Unfortunately there are concerns about the leading nature of questions in such forms (e.g., "Doctor, is this what you meant to say?"). For example, Sue Prophet, R.H.I.A., C.C.S., Director of Coding Policy and Compliance at AHIMA, strongly discourages the use of query forms as a substitute for documentation in the medical record. In her book entitled "Health Information Management Compliance, A Model for Healthcare Organizations," she described the query form as:

"...A process for ensuring that the physician documents in the health record any clarifications or additional information resulting from communications with coding staff should be established. Communication tools between coding personnel and physicians, such as coding summary sheets, attestation forms, or coding clarification forms (e.g., 'physician query forms'), should 'never' be used as a substitute for appropriate physician documentation in the health record."

Please note this memorandum is applicable to all Medicare and Medicaid Coding/DRG validation review activities conducted by IPRO. Should you have any questions in regard to this memorandum, please feel free to contact Renato Estrella or Dr. Cesar Limjoco.