People often ask me if I think ICD-10 will cause CDI Specialists to do more querying. In my opinion, yes.
I understand that queries from CDI Specialists don’t always tie to reimbursement. However, once claims experience is collected by Payers, I believe a strong tie between all queries and reimbursement will become apparent.
Introduction to Queries
If you’re new to queries, here’s a basic overview.
Queries play a crucial role in the coding and documentation of patient care. For inpatients, there are two types of queries: concurrent and retrospective. Concurrent queries are posed while the patient is still in the hospital, and the physician is available to provide clarification. These queries are preferred because they can improve patient care and outcomes while the patient is still being treated.
The retrospective query process, on the other hand, happens after the patient is discharged and can prevent billing if they’re not addressed. These queries often come from coding staff rather than CDI specialists. Retrospective queries aren’t the best, but they’re important to make sure billing is accurate and free of errors.
Queries can happen in both inpatient and outpatient settings. They help make clinical documentation more specific to support better care and billing. Here are a few examples of when queries might be used:
- If a patient has pneumonia, but it’s not clear if it’s bacterial or viral
- If a patient has a surgery that isn’t well-documented
- If a patient has a chronic condition that isn’t well-documented
CDI Specialists and coding professionals use different types of queries to make sure coding and documentation are accurate. By working together to clarify clinical documentation, they can help improve patient care and outcomes while also ensuring accurate reimbursement.
How the ICD-10 Might Affect Queries
With ICD-10, more knowledge is required to assign codes with greater specificity, especially for procedures. Procedures can impact the MS-DRG assigned and subsequently increase or decrease the payment weight. With ICD-10, there is no “unspecified out” with procedure coding, as all seven characters must be assigned to qualify as a complete code. This means that there is a greater need for clinical documentation that supports the level of specificity required by ICD-10.
CDI Specialists are likely to take on a larger query role with ICD-10, as the increased specificity in coding requires more knowledge and expertise. If questions arise about a procedure or diagnosis, CDI Specialists are likely to have the most immediate clinical knowledge to pose the inquiry. However, this doesn’t mean that coding staff won’t rise to the challenge; it’s simply a recognition that CDI Specialists may be better suited to handle the challenge out-of-the-gate.
Additionally, the added details in ICD-10 will result in increased opportunities for queries to be posed. This is something that CDI Specialists are likely preparing for without regard to the coding staff. As the transition to ICD-10 continues, healthcare organizations will need to ensure that their CDI Specialists and coding staff are working together to ensure accurate coding and documentation to prevent billing errors and ensure accurate reimbursement.
Final Thoughts
The reason I believe the CDI Specialists will take on a larger query role with ICD-10 is because of the increased anatomy, physiology, technical, and clinical knowledge required to assign codes with greater specificity – especially with procedure codes. Procedures can impact the MS-DRG assigned and subsequently increase/decrease the payment weight. There is no “unspecified out” with procedure coding because all seven characters must be assigned to qualify as a complete code.
If questions surface about a procedure, CDI Specialists are likely to have the most immediate clinical knowledge to pose the inquiry. That’s not to say your Coding Staff won’t rise to the occasion; it is acknowledgement that they may not be geared for the challenge out-of-the-gate.
Additionally, it stands to reason that added details in ICD-10 will result in increased opportunities for queries to be posed. This is something CDI Specialists are likely preparing for without regard to the Coding Staff. Every organization has unique and different skillsets. The best way to prepare for ICD-10 is to know where your strengths and weaknesses lie.
Want to learn more? See what ICD-10 compliance means for your organization today.
