Inpatient Queries: Clear Up Conflicting Messages
When documentation falls short, gather the facts and ask the question.
Clear up conflicting messages among providers using inpatient queries. Medical documentation is often confusing and inconsistent. Inpatient stays can last several days to several weeks and the patient’s condition can evolve greatly over the course of the hospital stay. There is also the myriad of consultants and specialists, each lending their opinions. The real fun begins when the myriad notes do not all support the same clinical picture.
Clinical parameters should be set by the providers for a specific diagnosis. Clinical best practices can be determined internally by a physician group, in concert with the hospital governing body. Clinical guidelines are defined as a systemically developed statement of clinical parameters used to assist with provider and patient decisions with regards to how best to care for a specific condition.
Prepare to Query
You do not need to be a clinician to gather and present the facts. The coder’s job is to gather the facts and pose the question. Queries can be used to determine what is really happening when there are conflicting diagnoses, or clinical parameters exist, which do not support a documented diagnosis. A query can also be drafted when clinical data does support a diagnosis that is not captured in the clinician’s notes.
The two GOLDEN RULES of queries are:
- Queries must be open ended, and
- Queries shall not be leading.
Over the past year, with COVID-19 on the scene, many admits cite “acute respiratory failure with hypoxia” in either the emergency department note or the admission history and physical (H&P) of the hospitalist’s note. Yet, the patient is described as “mildly distressed, on 2L of oxygen, afebrile, with a pulse ox reading of 95%.”
According to the exam, the patient is not using any accessory muscles of respiration and the respiratory rate is 22. Blood gasses were not drawn. The chest X-ray shows ground-glass opacities consistent with COVID pneumonia. The complete blood count is normal and without leukocytosis. The admitting physician’s assistant (PA) indicates in the Assessment and Plan diagnoses of COVID-19, COVID pneumonia, and respiratory failure with hypoxia. A day later, the pulmonologist indicates in the Assessment and Plan COVID-19 with COVID pneumonia. There is no mention of the respiratory failure in the discharge summary by the attending for the inpatient stay.
Dear <Provider Name>,
The admission H&P from 2/21/21 by PA____ indicates: “The patient was comfortable on 2L of oxygen, saturating at 95% with a respiratory rate of 22.” The admission H&P Assessment and Plan indicates: “COVID-19, COVID pneumonia, and acute respiratory failure with hypoxia.”
The pulmonology consult from 2/22/21 by Dr. _________indicates in the Assessment and Plan: “COVID-19 and COVID pneumonia.”
After consideration, can you determine if acute respiratory failure with hypoxia was ruled in or ruled out?
If acute respiratory failure with hypoxia was ruled in, was it present on admission?
Keep it simple, present the data you have, and always provide a point of reference such as the date and time of the entry in the medical record and the author, if appropriate. The coder does not have to make the determination of what the data means, the provider does.
- Inpatient Queries: Clear Up Conflicting Messages - June 1, 2021
- Clinical Parameters to Guide Provider Documentation Queries - August 2, 2016