What to Include in a Compliant Physician Query Policy

A comprehensive checklist for creating effective, consistent, and regulatory-aligned query policies.

A query policy must address many elements to facilitate a query process that generates compliant queries. Often, situations are not addressed until they become pertinent and the need to make a decision is urgent, leading to solutions created in a hurry and under pressure rather than with care and consideration. Creating a query policy well in advance of when it is needed, lends itself to developing a policy that is thoughtful and comprehensive.

Included here is a checklist of elements to be considered when developing an effective query policy.

Core Guidelines for When to Use or Avoid Queries

✔️ Identify situations when a query should NOT be sent

• Lack of business need
• Query does not add to the clarity of the clinical picture

✔️ Determine when to code from ancillary documentation that is signed by a physician, but not addressed in their documentation

✔️ Determine compliant query practices related to maintenance of the problem list (e.g., who can update a problem list based on a query response)

✔️ How will the organization report information that is clarified only within a query response versus elsewhere in the record?

Creating and Maintaining Standardized Query Templates

✔️ Format for creating query templates

• Obtain input/feedback on templates from providers and/or other disciplines, as appropriate

✔️ Will specific diagnoses have their own templates? If so, what are those diagnoses?

✔️ When will query templates be reviewed and updated (e.g., annually, when changes to a process occurs)?

✔️ Instructions on the use of templates

Determining Who Can Receive a Query

✔️ Will the organization query clinicians who are not classified as a provider?

Educating Stakeholders on the Query Process

✔️ Identify how individuals to whom queries may be sent will be educated about the reason(s) for the query, the process, and the expectations for completion and documentation.

Policies and Documentation Standards for Verbal Queries

✔️ Who can pose a verbal query

✔️ Under what circumstances may a verbal query be posed?

✔️ How will verbal queries be recorded?

✔️ Where will verbal queries be documented?

Compliance Standards for Query Templates and Query Audit Processes

✔️ What is the process for approving templates?

✔️ How will query validity be defined and measured?

✔️ Define the query audit processes

• What is the schedule for auditing?
• Who will perform the audits?

• Internal
• External
• Both

• Choose an audit tool

• What is the purpose of the tool?

• Qualitative and quantitative data

Managing Multiple Queries

✔️ Identify

• the number of queries that may be placed simultaneously and to how to prioritize query focus
• how many topics and questions may be issued in one query
• how many queries may be communicated during the same encounter

Using Clinical Criteria to Support Diagnosis Queries

✔️ Define what clinical criteria will be used to support specific diagnoses (e.g., Sepsis 2, Sepsis 3, Kidney Disease Improving Global Outcomes [KDIGO] ), American Society for Parenteral and Enteral Nutrition (ASPEN)

Best Practices for Query Timing and Encounter Resolution

✔️ Define when queries can be sent in relation to the timing of the encounter (e.g., prospective, concurrent, post discharge).

• It is best practice to send queries as close as possible to the time of the encounter.

✔️ Address the need to query more than 30 days post-discharge

✔️ How to handle queries that are unresolved before 30 days post-discharge (e.g., escalation)

✔️ For queries sent post-billing, how will encounters be rebilled if reimbursement is impacted?

Retaining and Storing Queries for Compliance and Auditing

✔️ The query retention policy needs to specify:

• what are the approved locations for query responses
• if the completed query will be a permanent part of the health record or considered as part of the business record
• How are addendums added to the health record and how are they authenticated?
• Queries may be disclosed and are retained for auditing, monitoring, and compliance.

Escalation Process for Unresolved or Disputed Queries

✔️ Outline expectations of each individual involved in the process

✔️ Specify expected time frames in which resolution or further escalation is expected

✔️ Specify with whom escalation will begin (e.g., supervisor, manager)

✔️ Specify to whom escalated queries will be referred to (e.g., physician advisor, chief medical advisor, or another administrative professional)

✔️ Outline what situations will be addressed by escalation

• Unanswered queries
• Medical staff concerns regarding queries
• Provider feedback communication process
• Lack of receipt of an appropriate professional response to a query

✔️ Specify how to handle query responses

• that do not provide the clarity requested
• that are identified as non-compliant

✔️ Outline how to handle situations where the provider feels the query is unnecessary. (e.g., include a query response option of “no further clarification is needed” or “Query unnecessary”)

Guidelines for Referencing Prior Encounters in a Query

✔️ When and for what reasons can prior encounters be reviewed?

✔️ How old can the records be?

For expanded information about navigating the query process, explore our course Composing an Effective and Compliant Physician Query in HIAlearn.

Reference

• Guidelines for Achieving a Compliant Query Practice—2022 Update

For more than 30 years, HIA has been the leading provider of compliance audits, coding support services and clinical documentation audit services for hospitals, ambulatory surgery centers, physician groups and other healthcare entities. HIA offers PRN support as well as total outsource support.

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.