CMS Policy Clarification on Coding Compliance--Use of Physician Query Forms

DEPARTMENT OF HEALTH & HUMAN SERVICES

Health Care Financing Administration


7500 SECURITY BOULEVARD

BALTIMORE MD 21244-1850

QIP TOPS CONTROL NUMBER: PRO 2001-13

DATE: October 11, 2001

FROM:
Director
  Quality Improvement Group
  Office of Clinical Standards and Quality

SUBJECT: Coding Compliance - Use of Physician Query Forms

TO: 
Associate Regional Administrators, DCSQ
  Regions I, VI, VII, IX  
  Chief Executive Officers, All PROs

Policy Clarification

This TOPS is effective immediately and supercedes TOPS 2001-03 and TOPS 2001-06.

In conducting medical review for validating the DRG, the PRO reviewer shall use his or her professional judgment and discretion in considering the information contained on a physician query form along with the rest of the medical record for purposes of DRG validation.  If the physician query form is leading in nature or if it introduces new information, the reviewer shall refer the case to the physician for review.  The PRO must perform physician review as described in the PRO Manual at 4130(D) and provide the opportunity for discussion if necessary.

Background

The purpose of DRG validation is to ensure that diagnostic and procedural information and the discharge status of the patient, as coded by the hospital on its claim, match the information contained in the patient's medical record.  The medical record must meet the requirements set forth in 42 CFR 482.24(c).

In January 2001, we issued TOPS 2001-03 directing PROs not to accept physician query forms as documentation in the medical record when following DRG validation procedures specified in Section 4130 of the PRO Manual.  In enunciating the query-form position, we did not mandate an outright prohibition of the use of physician query forms.  Rather, we prohibited PROs from using physician query forms as a substitute for documentation in the medical record.  That memorandum generated significant response from interested parties.  We subsequently recognized that there are varied interpretations of what constitutes proper supplemental usage of physician query forms.  As a result, TOPS 2001-06 placed TOPS 2001-03 in abeyance until October 1, 2001.

In reevaluating our policy, we determined that physician query forms are primarily used as a communication and educational device within a hospital and their submission as documentation is minimal.  We considered comments from a variety of sources regarding the appropriate role of physician query forms in the medical record.  Those comments were highly variable and it is clear that health care facilities adapt these forms to meet their individual needs.  We recognize that flexibility is necessary to allow this individualized adaptation to occur.

We also recognize that there are practices associated with the physician query forms that are generally considered acceptable within the health care industry.  However, we defer the promulgation of specific guidelines addressing these practices to health information management experts and organizations.  Our position allows the use of the physician query form to the extent it provides clarification and is consistent with other medical record documentation.  In addition, it addresses our concerns about leading questions and introducing information not otherwise contained in the medical record.  Finally, the policy encourages dialogue between the hospital and the PRO physician reviewer on the acceptable use of query forms.

If you have any questions, please contact Tim Carr at (410) 786-5050 or Sheila Blackstock at (410) 786-3502.

/s/
Stephen F. Jencks, MD, MPH