Exit this survey 2013 Physician Queries Benchmarking Survey 50% of survey complete. Question Title * 1. Are you a CDI specialist? 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) Question Title * 2. What type of queries does your CDI program issue (check all that apply)? Concurrent Retrospective (pre-bill) Post-bill Other, please specify Question Title * 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 Question Title * 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 Question Title * 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 Question Title * 6. Which of the following techniques do you find most effective when querying a physician? 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 Question Title * 7. Which department follows up on/closes out outstanding queries after the patient is discharged? CDI department HIM/coding department Case management Any department, depending on query type Don’t know Other, please specify Question Title * 8. Do you use templates in your written/electronic queries? Yes, always Yes, frequently Yes, occasionally No, never Other, please specify Question Title * 9. Where did you obtain your information or source for the query templates/forms (check all that apply)? Association guidance (ACDIS, AHIMA, other) Coding manuals Consultants CMS/Medicare Administrative Contractor guidance Medical journals Physicians We do not use templates Other, please specify Question Title * 10. Who was involved in developing your query templates/forms (check all that apply)? 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 Question Title * 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 Question Title * 12. Do your query forms follow the American Health Information Management Association (AHIMA) physician query guidance? 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 Question Title * 13. Does your facility have standard query policies and procedures? 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) Question Title * 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 Question Title * 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 Question Title * 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 Question Title * 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 Question Title * 18. Are your query forms part of the patient’s permanent medical record? 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 Question Title * 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 Question Title * 20. Which of the following items do you track in regard to query dissemination and physician response (check all that apply)? 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 Question Title * 21. Which of the following do you audit/monitor as indicators for query performance (check all that apply)? 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 Question Title * 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 Question Title * 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 Question Title * 24. Do you audit/monitor the following indicators for query quality (check all that apply)? 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 Next