The best practice is to add any retrospective query response as an addendum to the health record.
Although the goal of clinical documentation integrity (CDI) professionals is to issue queries concurrently, there is a subset of queries, often related to performance on quality-of-care measures (i.e., mortality) that are issued retrospectively. Recently, I’ve received a few inquiries by CDI professionals because providers at their organization are pushing back against retrospective queries, claiming they are improper or even fraudulent, so they will not even respond. So, what are the rules when it comes to retrospective queries? Or, better yet, are there any rules related to retrospective queries?
The irony is, at one time, all queries were retrospective because they were the domain of the coding department, which didn’t identify query opportunities until the coding process began. Yes, in an ideal world, queries would be issued and resolved concurrently, while the patient is still in-house. Concurrent queries allow the relevant diagnosis to be captured while patient care is being rendered, supporting continuity of care as well as providing the coder with a complete and accurate record to expedite the coding process. However, most processes for identifying cases that may be included in quality-of-care measures are post-discharge, if not retrospective, because many quality-of-care measures are identified by the ICD-10-CM and ICD-10-PCS codes that are included on the claim. As CDI professionals become more involved with quality-of-care measures, providers are likely to continue to see retrospective queries.
Are there rules related to retrospective queries? Unfortunately, like many things CDI, there is not one clear source with a definitive answer. Yes, retrospective queries are allowable, but is there a deadline as to how long after discharge a query can be asked? No. To find an answer, it’s best to examine guidelines associated with making changes to the medical record.
First, it is important to note that providers do have an obligation to adhere to general principles of medical record documentation. According to the Evaluation and Management Services Guide (February 2021), the following general principles apply:
- The medical record should be complete and legible
- The documentation of each patient encounter should include:
- Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results
- Assessment, clinical impression, or diagnosis
- Medical plan of care
- If date and legible identity of the observer if the rationale for ordering diagnostic and other ancillary services is not documented, it should be easily inferred
- Past and present diagnoses should be accessible to the treating and/or consulting physician
- Appropriate health risk factors should be identified
- The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented
- The diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by documentation in the medical record
The Medicare Program Integrity Manual states that “all services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered. Occasionally, certain entries related to services provided are not properly documented. In this event, the documentation will need to be amended, corrected, or entered after rendering the service. When making review determinations, the MACs (Medicare Administrative Contractors), CERT (Comprehensive Error Rate Testing), Recovery Auditors, SMRCs (Supplemental Medical Review Contractors) and UPICs (Unified Program Integrity Contractors) shall consider all submitted entries that comply with the widely accepted Recordkeeping Principles … the MACs, CERT, Recovery Auditors, SMRC, and UPICs shall NOT consider any entries that do not comply with the principles listed in section B below (Recordkeeping Principals), even if such exclusion would lead to a claim denial. For example, they shall not consider undated or unsigned entries handwritten in the margin of a document. Instead, they shall exclude these entries from consideration.”
These Recordkeeping Principals apply to both paper and electronic health records that contain amendments, corrections, or late entries, which are the three ways a provider can compliantly alter their documentation within the health record:
- An addendum is used to provide information that was not available at the original time of entry, and should include the reason for the addition or clarification of information being added to the medical record
- A late entry is a record amendment used to add information that was omitted during the original entry, or
- A correction is used when a prior entry was made in error. A correction should not obliterate the initial entry.
Although many organizations allow providers to respond directly to a query, depending on the timing of the query (e.g., if it is concurrent or retrospective), a best practice would be to add any retrospective query response as an addendum to the health record, to comply with Recordkeeping Principals. As long as the response to the retrospective query is correctly added to the health record, it is not falsified documentation. According to Noridian Healthcare Solutions, a MAC for the Centers for Medicare & Medicaid Services (CMS), examples of what can be considered falsifying a health record include the following:
- Creation of a new record when a record is completed;
- Back-dating entries;
- Post-dating entries;
- Pre-dating entries;
- Writing over; and
- Adding existing documentation (except as described in late entries, addendums, and corrections).
Noridian does not reference an acceptable timeframe when record amendments can or cannot occur, but they do state that “corrections to the medical record legally amended before claims submission and/or medical review will be considered in determining the validity of services billed. If these changes appear in the record following payment determination based on medical review, only the original record will be reviewed in determining payment of services billed to Medicare.” Suggesting that queries to add documentation to refute a denial from a MAC is likely futile.
Perhaps the best guidance regarding how a CMS contractor should process clinical information derived from a query comes from Risk Adjustment Data Validation (RADV) contractors, which support audits related to the Medicare Advantage (MA) program. Their contractor reviewer guidelines include a section on query forms. Included in the guidance is a simple but accurate description of a query: “a tool used to clarify documentation in the health record for accurate code assignment.” The guidance also builds upon the definition of a query within the glossary, with a very thoughtful description: “the desired outcome from a query is an update (an “update” can be a late entry, addendum, or approved query form, per individual facility medical record documentation policy) of a health record to better reflect a practitioner’s intent and clinical thought processes, documented in a manner that supports accurate code assignment.”
This addition, how the record update should occur (e.g., in the form of an addendum), should be an important component of any organization’s query process. If the provider is not required to amend the discharge summary to support a retrospective query, then the query form should be designed to act as an addendum to the health record and meet all the Recordkeeping Principals.
RADV guidance related to the acceptance of query forms is as follows: “when submitted with the associated medical record, diagnosis query forms that are completed, signed, and dated promptly (i.e., within 90 days of the date of service) by the physician/practitioner and became part of the official medical record will be reviewed for validity and clinical consistency with the medical record documentation.”
This guidance contrasts with what was issued in 2004, as referenced in the article, “Querying Physicians to Improve Documentation and Dx Coding” (Barton, D. 2017), which references that “the correction should be within 30 days of the initial documentation, and substantial reasoning must be provided for the change.” Most organizations will likely remain within a 30-day time frame when it comes to retrospective queries due to the potential impact on facility metrics like days of bill hold, and the potential issues associated with rebilling a claim, so maybe this discrepancy is not an issue for most organizations.
What is particularly interesting regarding the RADV guidance is that it also clearly states whose documentation can and cannot be used to amend the health record, stating, “only the attending or treating physician can amend the medical record … it is not appropriate to add diagnoses to the medical record that have been identified by a source other than the treating physician (e.g., identifying diabetes from a disease management program).”
Although this seems like a reasonable requirement, I have heard discussions regarding the use of non-treating providers to amend health records as a way to “expedite” the query process. As more CDI departments have physician advisors who see patients, it is important to clearly outline when the physician advisor may document in a health record. A best practice would be to include a policy that only allows a member of the medical staff to document a patient’s health record when they are part of the treating medical team.
The RADV guidance also elaborates upon who can perform queries:
“Query type forms generated by the MA organization, or their coding staff contractors, are not acceptable for review as part of the medical record. They are considered extraneous data from an alternative data source not allowed, per risk-adjustment policy.”
“Query forms will be considered on a case-by-case basis to determine whether the document is an acceptable standard physician query made by a coder or similar facility staff at or near the time of the encounter, or if it is some other unacceptable late addition of conditions after the original encounter.”
“RADV reviewer will not code from documents even if labeled (incorrectly) as ‘coder query’ if the documentation is not generated at or near the time of the encounter by the facility or physician office.”
The query process is the responsibility of the organization’s CDI or coding staff, and responding to a query is the responsibility of a treating provider. Querying is a complex process, and it involves coordination between CDI and coding professionals with the treating medical team, as well as other members of the health information management team who manage and release the health record. Often, multiple sources of information must be cobbled together to create a compliant process. When it comes to a compliant query process, it is not only important to understand the rules pertaining to that process, but also the rules for amending the health record. Embracing these rules can grow physician support for retrospective queries by helping them understand that record amendments are an ethical and compliant process, accepted by CMS.