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Claim denials often based on diagnoses written in query

14 Apr 2019

What auditors look for in your documentation

By: Patti Moore BSN, RN, CCDS

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Clinical documentation specialists are getting more involved in helping you avoid claims denials. Please note these tips and insights to ensure fast and accurate claims processing.

Queries are official records: When a clinical documentation specialist sends a query to a provider, that provider has the option of answering the query within the query itself and/or by documentation within a note (e.g., H&P, progress note, procedure note, consult, discharge summary).

At Salem Health, a query and all responses are permanent parts of the patient’s chart.

Denials come from queries: We have discovered a huge number of denials based on diagnoses written within a query and noted nowhere else within the chart. To an external auditor, the diagnosis appears inaccurate when not added to any note. For example, if a patient has severe sepsis, acute respiratory failure, severe malnutrition, CAUTI or acute CHF, one would expect to find this documentation throughout the chart, noted by multiple providers.

Add to your progress notes: One challenge of answering only in a query (and not carrying it through to progress notes) is that other providers may not be aware of the new information you may have supplied. When an auditor does not find the diagnosis outside of a query, they may assume that the diagnosis is invalid.

How to help us:  Your CDS will continue to support your authority as diagnosticians by appealing these unfair denials. However, we cannot guarantee that a denial appeal will be accepted as valid simply because we point out that our provider did, in fact, provide a diagnosis via query response. 

Please join the effort to enrich documentation and reduce denials by adding query responses and associated clinical findings into your chart notes.