Wiki Coding a Diagnosis Based on a Query

[RaeToll]

The payor denied this inpatient claim for the principal diagnosis of sepsis as the condition was not mentioned within the medical record, and only documented in a physician coding query. Can we bill a diagnosis based on indicators and a coding query, even if not mentioned in the medical record? Can anyone provide any reference to this?

 

[thomas7331]

The payor denied this inpatient claim for the principal diagnosis of sepsis as the condition was not mentioned within the medical record, and only documented in a physician coding query. Can we bill a diagnosis based on indicators and a coding query, even if not mentioned in the medical record? Can anyone provide any reference to this?

Most organizations that have a formal query process will require the inclusion of any queries as part of the medical record, and code assignment from the provider's responses are considered valid. But if your query is informally made, e.g. in the form of an email to the provider outside of the records process, it could be considered a noncompliant query, in which case I imagine a payer might not consider it valid. I'd caution though that in this particular situation the payer may not allow the diagnosis even if they acknowledge the provider's statement - in my experience with audits related to sepsis, payers are looking from more than just a provider statement alone, and will often not allow the sepsis diagnosis unless all of their clinical criteria to justify the diagnosis are also supported in the record.

Here's a link to a good article from AHIMA about compliant query processes that might help:

https://bok.ahima.org/doc?oid=302673#.YfvvPzYUqUk

A couple of sections that are of relevance to your question:

Best practice dictates that, whenever possible, query responses be consistently documented within the health record as part of the progress notes and discharge summary or as an addendum as appropriate. If a compliant query has been properly answered and authenticated by a responsible provider and is part of the permanent health record, absence of the documented answer in a progress note, discharge summary, or addendum should not prohibit code assignment.

While organizations are free to determine the specifics of their query process, compliant practice requires that all queries either be a permanent part of the record or be retrievable in the business record.

It is recommended that the policy specify the completed query be a permanent part of the health record and the location. If it is not considered a permanent part of the health record, it should be considered as part of the business record and retained for auditing, monitoring, and compliance. If the query is deemed to be part of the health record, it will be subject to health record retention guidelines which vary from state to state.