Managing the Physician Query Process

Vol. 11 •Issue 20 • Page 30
Managing the Physician Query Process

How to walk the thin line between getting the answers you need and pleasing the OIG.

To physicians, it’s red tape. It’s time spent away from patients. It’s not what they went into medicine for. It’s just paperwork. To health information management (HIM) professionals, on the other hand, it’s documentation vital to proper patient care, not to mention reimbursement.

This variation in perception is only one of the contributing factors to difficulty in the physician query process. Other reasons, according to Joette Derricks, CHC, CPC, CMPE, CEO and president of Healthcare Management Solutions Inc. in Harrisburg, PA, include “time constraints, lack of commitment to the organization’s objectives and needs, and lack of understanding of their role in the process.”

And physicians aren’t the only ones HIM professionals have to please. They must also do their best to ensure that they are getting the information they need without putting words in the resistant doctors’ mouths, lest their actions be misconstrued by the Office of Inspector General (OIG).

None of these obstacles, however, are insurmountable. Taking the time to evaluate your procedures, as well as to understand what makes some physicians uncooperative and how best to address their concerns, can go a long way toward making your physician query process more effective–and more pleasant.

The Root of the Problem

Let’s start with a bit of history. “Following the elimination of the attestation requirement, the OIG focused on making sure the proper documentation was there to support the code,” stated Sue Prophet, RHIA, CCS, director of classification and coding for the American Health Information Management Association (AHIMA). “The idea of querying the physician kind of proliferated and grew.”

Facilities started developing different forms to help them get the answers they needed from physicians–and in a few cases, the answers they wanted. “The initial intent for many of these physician query sheets was maximization for DRGs,” stated Arlene Baril, MS, RHIA, operations manager with Pyramid Health Solutions Inc. in Plano, TX.

“In fact, there were even companies that marketed their forms for that specific purpose, calling them ‘physician prompt sheets.’ However, the OIG did not like that physicians were being asked to tailor their documentation for reimbursement purposes.”

And thus began the battle over physician query forms–whether they were acceptable as a form of communication and just how they should be structured. This past July, Prophet penned testimony read at the Office of Clinical Standards and Quality at the Centers for Medicare and Medicaid Services (CMS) Physician Query Form Town Hall Meeting. Representing AHIMA, she wrote, “We believe the vast majority of query forms are not used with fraudulent intent, and therefore, using query forms should not immediately be interpreted as an indication of fraud and abuse.”

In addition, Prophet urged the use of the organization’s practice brief titled “Developing a Physician Query Process” (available at as a guideline for acceptable practice and use of physician query forms.

While a ruling from CMS is still forthcoming, it seems that physician query forms will continue to be used for some time. For the meantime, each state’s peer review organization (PRO) is responsible for determining what forms are acceptable. For a list of PROs and their contact information, visit

Getting It Right

So how can you be sure that your approach to physician queries is up to muster?

By taking the process seriously.

“The query process should be included in your policies and procedures,” advised Baril. “What process are you going to use? Will the completed form be part of the medical record? If so, you have to change your bylaws to specify that coders can make contributions to the record. These are the type of things that should be considered.”

In addition, Baril emphasized that it is important to include your facility’s forms committee and legal counsel in the process.

Someone else you may consider including in the development of your physician query process is the physicians themselves. “Involve them upfront in the collaboration,” suggested Prophet. “It’s important to get them to buy in to a process they are going to be a part of.”

When developing your query form, it’s vital to keep in mind the OIG’s concerns. Ideally, it should give the physicians enough information to come to their own decisions, without appearing to coach them or push them toward a particular answer.

A simple “yes or no” check sheet is not acceptable.

“The form should be precise so the physician knows what is being asked and gives the most specific response possible,” explained Prophet. “Referencing the clinical findings, test results, or physician’s statements that prompted the query helps trigger the physician’s memory.”

“Do not use any phrasing that would indicate that you are motivated by any kind of financial incentive,” added Baril. “And be sure to include important information such as the patient name, ID number, date and physician’s signature.”

Fighting Resistance

No matter how well defined your process and perfect your forms, there are still going to be physicians who are resistant. In many cases, according to Derricks, this can simply be a matter of “educating the physicians on the value to the organization of responding timely.”

Education can either be done one-on-one, on an as-needed basis or in a more formal manner.

“Open up a dialogue between the physicians and the HIM staff,” stated Derricks. “Make it a team effort.”

At Sacred Heart Medical Center in Spokane, WA, they broach the subject with a bit of humor. In a joint effort with other facilities in the Spokane area, they developed the “Duckumentation” program.

“Our mascot is a duck with an OIG badge,” explained Jean Carman, RHIA, MBA, CPA. “Our slogan is ‘If it looks like a duck, acts like a duck and walks like a duck, it still isn’t a duck until you say it’s a duck.”

Posters around the facility feature the mascot provide a new documentation guideline each time. “We are trying to get the information out there in small bites,” stated Carman.

The program seems to be working at Sacred Heart, but keep in mind that every facility is different. Education efforts should be tailored to your organization’s needs.

But whatever approach you choose, make sure that the subject is approached in a friendly manner. “It needs to be a collaborative educational process,” added Prophet. “You don’t want the physicians to perceive this as another case of the ‘HIM police’ telling them what to do.”

Sometimes, however, a physician’s resistance is absolutely valid. “One of the nice things about doing the queries is that you can do some auditing,” stated Baril. “That works two ways. It will tell you if you’ve got a physician who has consistent documentation deficiencies. But it can also show if a coder is consistently questioning the same thing repeatedly. That may indicate that the coder doesn’t quite understand a particular disease process.”

In addition, noted Prophet, physicians also complain that they often don’t understand what triggered the query in the first place.

Auditing the physician queries can give you valuable insight into how the process is working, ensure that the queries are appropriate and allow you to focus in on specific problems.

Another way to increase cooperation in the query process is by auditing physicians’ needs and doing your best to conform the process to them. “Some like to come here, some prefer to have the queries delivered to them. There is no set formula,” stated Baril. “We do whatever is most convenient for the physicians.”

Make it as easy on them as possible by ensuring they have sufficient time and access to records as well. “Sometimes a physician does not have access to the patient record at the time he or she is asked to answer a question and may not remember enough to give an informed decision,” stated Prophet. “Allow physicians sufficient time to review the records before providing an answer.”

Finally, don’t lose sight of what the query process is all about. “Remember that the point of the query process is to improve documentation,” advised Prophet. “Therefore, they should be done not only when they will result in assigning a diagnosis with higher reimbursement, but also when it will result in less money.”

Gretchen Berry is an associate editor at ADVANCE.