ISSUE: Use of Physician Query Forms

Background:

In January, 2001, we issued PRO TOPS 2001-03 which specified that PROs are not to accept coding summary forms (e.g., Physician Query Forms) as a substitute for documentation in the medical record for DRG validation purposes.

In enunciating the query-form position (essentially a reiteration of our long-standing policy that there is no substitute for proper documentation in the medical record), CMS did not mandate an outright prohibition of the use of summary forms.  Rather, we prohibited PROs from considering coding summary forms as a substitute for documentation in the medical record.  We acknowledge that such forms may have limited value as a supplement to the medical record and serve as important communication tools within hospitals.

Varied interpretations of what constitutes proper supplemental usage of coding summary forms, with possible business consequences not previously contemplated, caused us to suspend that policy pending resolution of these issues and/or achievement of mutual agreement with the provider community on acceptable alternative approaches.

Consequently, we published notification of a Town Hall Meeting and invited public comment on the use of physician query forms in the Federal Register (FR/ Vol. 66, No. 128/ p. 35260). Nearly 80 people attended our July 27 Town Hall Meeting in Baltimore to hear and discuss CMS's position, as well as the testimony of seven others representing personal and industry views. Their views almost uniformly support a formal query form process and inclusion of a hospital-approved physician query form as a permanent part of the medical record.

Additionally, we received 123 written responses (including 7 from PROs), the majority of which support the use of facility approved physician query forms as a stand-alone, permanent part of the medical record.  Only 8 negative opinions were voiced, 5 of them from the PROs.

At both the Town Hall meeting and in correspondence, there was also widespread support for "guidelines" from either CMS or industry representatives (such as AHA Coding Clinic and/or AHIMA) to govern query form content and processes.  [The process outlined in AHIMA's practice brief entitled "Developing a Physician Query Process" was cited as a reasonable starting outline for implementation.]

Moreover, on the basis of public comment pursuant to CMS's solicitation in the Federal Register and our Town Hall Meeting of July 27, 2001, CMS has revised its position.

Policy Clarification:

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.  If the physician query form is leading in nature or if it introduces new information, the case shall be referred to a PRO physician for further review.  The PRO must perform physician review as described in the PRO Manual at 4130(D) and provide the opportunity for discussion if necessary.

This position has been communicated to the Peer Review Organizations via a new TOPS document (PRO TOPS 2001-13), which supersedes both PRO TOPS 2001-03 and PRO TOPS 2001-06, and is being shared with our colleagues at the OIG and DOJ.

Summary

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.


Source: Centers for Medicare and Medicaid Services. Quality Improvement Organization (QIO) Program (October 2001)