Are Leading Queries Prohibited by Law or Lore?

October 13th, 2022 - Erica E. Remer
Categories:   Audits/Auditing  

AHIMA released its CDI Practice Brief Monday.

At Yom Kippur services, I found myself thinking about the question Dr. Ronald Hirsch posed to me the day before. My rabbi was talking in her sermon about the difference between halacha and minhag.

Halacha is law; it is the prescriptions and proscriptions set in the Bible and other rabbinic legislation. Thou shalt not murder; Honor thy father and mother; rules for celebrating post-Biblical holidays. Minhag is tradition or custom, and, although the practices may have become so commonplace as to be near universal, they are not derived from law, per se. Wearing a head covering (i.e., a yarmulke or kippah) in the synagogue and avoiding rice, lentils, and legumes at Passover in the Ashkenazi tradition are examples of minhagim (the plural of minhag).

The question that was posed by a listener of Monitor Mondays was, “Does the law prohibit leading questions in queries?” and they asked for a source. There was no time to answer on air, and Ron (Dr. Ronald Hirsch, MD) kicked the football to me. Behind the scenes, healthcare attorneys David Glaser and Knicole Emanuel both concurred that there is no law, rule, or regulation prohibiting leading queries, and I agree. However, there is more to this.

One of the hardest things I had to do as a physician advisor was wrap my head around the term, “compliance.” I finally settled on it indicating going along with the rules, which to me implied the government’s rules, regulations, and laws. However, in addition to external requirements, compliance can reflect following your organization’s internal rules, policies and procedures, and acting in accordance with ethical practices. Laws, rules, and regulations are halacha; industry standards and organization’s internal rules, policies and procedures are minhag.

What is a leading query? It is a request for clarification that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or procedure. If it is not supported by the clinical indicators, then it will not be a valid condition, even if documented in the record.

Attempting to guide the provider into desired documentation for reimbursement or quality reasons is also noncompliant. Only the clinician caring for the patient is qualified to make diagnoses; clnical documentation integrity specialists (CDISs) must not overreach.

...

Read the entire article at ICD10monitor by clicking here.

This article originally published on October 10, 2022 by ICD10monitor.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Artificial Intelligence in Healthcare - A Medical Coder's Perspective
December 26th, 2023 - Aimee Wilcox
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities? 
Specialization: Your Advantage as a Medical Coding Contractor
December 22nd, 2023 - Find-A-Code
Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)
December 19th, 2023 - Aimee Wilcox
Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.
Changes to COVID-19 Vaccines Strike Again
December 12th, 2023 - Aimee Wilcox
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for Appendicitis
November 14th, 2023 - Aimee Wilcox
With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....



Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association