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2013 Physician Queries Benchmarking Survey
50%
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1.
Are you a CDI specialist?
(Required.)
Yes
No, I am a CDI manager/director
No, I am an HIM/Coding manager/director
No, I am a HIM/Coding professional
No, I am a consultant
No, I am a physician advisor
Other (please specify)
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2.
What type of queries does your CDI program issue (check all that apply)?
(Required.)
Concurrent
Retrospective (pre-bill)
Post-bill
Other, please specify
3.
What is the frequency of your concurrent review?
Daily
Every other day
Weekly
At time of admission and discharge
We do not perform concurrent reviews
Other, please specify
4.
What type of queries does your CDI program
prioritize
?
DRG shift (financial impact)
Severity of Illness (SOI)/Risk of Mortality (ROM)
Quality or core measures
Any documentation that requires clarification, regardless of impact
Other, please specify
5.
Are the majority of your queries
Written (paper-based)
Written (electronic)
Verbal (face-to-face)
Roughly equal mix of verbal and written
Other, please specify
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6.
Which of the following techniques do you find most effective when querying a physician?
(Required.)
Leave a paper query in the patient’s medical record
Leave electronic message in the medical record (for those with an EMR)
Verbal conversation/discussion
E-mail the physician directly
Fax the physician office
Hand a query form to the physician
Hand the query form to a physician extender (e.g., physician assistant, case manager, nurse practitioner)
Other, please specify
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7.
Which department follows up on/closes out outstanding queries after the patient is discharged?
(Required.)
CDI department
HIM/coding department
Case management
Any department, depending on query type
Don’t know
Other, please specify
8.
Do you use templates in your written/electronic queries?
Yes, always
Yes, frequently
Yes, occasionally
No, never
Other, please specify
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9.
Where did you obtain your information or source for the query templates/forms (check all that apply)?
(Required.)
Association guidance (ACDIS, AHIMA, other)
Coding manuals
Consultants
CMS/Medicare Administrative Contractor guidance
Medical journals
Physicians
We do not use templates
Other, please specify
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10.
Who was involved in developing your query templates/forms (check all that apply)?
(Required.)
CDI staff
Physician advisor/champion
Other medical staff
HIM/coding staff
Nursing staff
CDI manager
Case management staff
Legal department
Compliance department
Primarily from a consultant or a software vendor
We do not use templates
Other, please specify
11.
What elements do your query templates contain (check all that apply)?
Space to include specific clinical data from the patient’s medical record
Relevant coding references
Organizational or industry standard definitions for common diagnoses
Specific diagnosis phrase(s) options
Open ended options (other, can not determine, etc.)
Pre- and post-query DRG
DRG relative weights
Severity of illness/Risk of mortality information
We do not use templates
Other, please specify
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12.
Do your query forms follow the American Health Information Management Association (AHIMA) physician query guidance?
(Required.)
Yes, fully.
Yes, partially. We have read the guidance and included applicable suggestions in our CDI program policies and procedures
Yes, partially. We have separate policies for CDI specialists/HIM staff. The HIM/coders adhere to AHIMA guidance but CDI specialists do not
Don’t know/have not read latest guidance
No, we follow our own internal set of query guidelines
Other, please specify
*
13.
Does your facility have standard query policies and procedures?
(Required.)
Yes, for all queries types regardless of department
Yes, but they only apply to written queries
Yes, but they only apply to coding staff
Yes, but they only apply to verbal queries
No
Don’t know
Other (please specify)
14.
If your facility has a standard policy for verbal/written queries, who created it? Check all that apply.
CDI department
HIM/coding department
Compliance department
Physicians/medical staff
A task force including participants from CDI, compliance, HIM, finance, case management, medical staff
A consulting company
Borrowed an existing policy from ACDIS website/book
Don’t know
Other, please specify
15.
Do you query for clarity, completeness, severity, specificity, etc. when the query does not affect reimbursement?
Yes, always
Yes, frequently
Yes, occasionally
Yes, but rarely
No, never
No, but we plan to in the future
Other, please specify
16.
Does your facility have an electronic query system either as part of your EMR or another software system?
Yes
No
No, but we are in the process of implementing one
Other, please specify
17.
If you have an electronic query system, does it:
Include standard query templates
Provide audit and reporting capabilities
Improve CDI productivity
Enable coder/CDI specialist communication
Include additional physician communication options
We do not have an electronic query system
Other, please specify
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18.
Are your query forms part of the patient’s permanent medical record?
(Required.)
Yes
No
No, but they are archived as administrative information
Some are a permanent part of the record and some are not
Don’t know
Other, please specify
19.
If your query forms are not a permanent part of the medical record, do you provide the query as part of Recovery Auditor, legal, or external audit requests?
Yes, all queries are submitted to the auditor
No, we never submit the queries
We submit only those queries that are a permanent part of the record
Don’t know
Other, please specify
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20.
Which of the following items do you track in regard to query dissemination and physician response (check all that apply)?
(Required.)
Origin of inquiry (i.e., CDI specialist or coding staff member)
Name of person issuing query
Name of the physician queried
Method of query (i.e., written or verbal)
Paraphrase of the question asked (if verbal query was presented)
Focus of query (CC/MCC, primary diagnosis, procedure, SOI/ROM, etc)
Paraphrase of physician response (if verbal query was presented)
Physician agreement
Other, please specify
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21.
Which of the following do you audit/monitor as indicators for query performance (check all that apply)?
(Required.)
Initial DRG
Potential DRG (what DRG would be if provider responded in the affirmative)
Working DRG
Final DRG
CDI specialist/coder agreement
Number of records reviewed per day
Number of re-reviews per day per staff member
CC/MCC capture rate
Rates of queries issued by CDI specialist (% of total charts reviewed, % of discharged records/reviewer)
Rates of queries administered to individual physicians
Financial impact of queries
SOI/other impact of queries
Percentage of positive and negative query responses
Other, please specify
22.
How often do you review/audit your query forms for compliance?
Monthly
Quarterly
Biannually
Yearly
Once every two or three years
As needed
We do not review them
Other, please specify
23.
If you answered yes to question 22, who reviews/audits your query forms for compliance (check all that apply)?
Self auditing
CDI peers
CDI manager/leader
Consultant
Compliance department
HIM/coding department
Physician advisor/champion to CDI
Other, please specify
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24.
Do you audit/monitor the following indicators for query quality (check all that apply)?
(Required.)
Unnecessary queries
Leading queries
Poor choice of wording /clarity
Missed query opportunity
Noncompliance with query standards (AHIMA or internal policies and procedures)
Not clinically appropriate and supported
Inaccurate information on the query form
We don’t monitor queries for quality
Other, please specify