Administrative Memos

200121

FROM: Theodore O. Will, Chief Executive Officer
DATE: Dec 06, 2001
SUBJECT: Centers for Medicare/ Medicaid Services (CMS) Update in Regard to the Hospital use of Query Forms and DRG Validation Review
IPRO CONTACTS:

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

In March 2001, based on information received from CMS (formerly HCFA), IPRO issued a memorandum entitled "Clarification in Regard to DRG Validation and the Use of Physician Query Forms by Hospital Information Management Personnel" (Reference: Medicare Administration Memorandum #2001-01; Medicaid Administrative Memorandum #2001-04; and PEPP Administrative Memorandum #2001-03). The memorandum reiterated the CMS position that "the use of physician query forms is not an acceptable substitute for physician documentation in the medical record."

Subsequently, in response to the many public comments received in regard to the use of query forms, CMS issued a temporary suspension of their policy statement (upon which our March memorandum was based) to allow time for discussion and further study in regard to their use. In July 2001, CMS hosted a Town Meeting to formally seek comments from all interested parties. As a result of their fact-finding, CMS has re-evaluated their policy in regard to the use of query forms and their relationship to PRO DRG validation review.

Therefore, in accordance with the new CMS directive, when conducting DRG validation review the IPRO non-physician reviewer shall use his/her professional judgement and discretion in considering the information contained on a physician query form along with documentation in the medical record. If the query form is leading in nature and/or it introduces new information not contained in the medical record, the case shall be referred to a physician consultant for review in accordance with IPRO's Medicare/Medicaid case review process. As always, should a potential concern be identified by the physician consultant reviewing the case, the hospital will be notified and an opportunity for response afforded.

Should you have any questions in regard to this memorandum, please feel free to contact Renato Estrella or Dr. Cesar Limjoco.