Achieving a Compliant Query Practice

Clinical documentation improvement (CDI) is essential for accurate patient care, compliance, and effective risk adjustment. Health plans and providers must work together to address common challenges like incomplete records, workflow disruptions, and slow technology adoption. By integrating solutions that fit seamlessly into provider workflows—whether through EMR-compatible platforms or flexible engagement models—health plans can reduce administrative burdens while ensuring compliance with CMS guidelines and HIPAA requirements.

This episode explores best practices for health plans to support providers with clinical documentation and how proactive risk adjustment strategies improve efficiency by addressing documentation gaps upfront, reducing costly retrospective corrections.

Listen to this episode to learn how to build a stronger partnership between health plans and providers, improve compliance, and enhance operational efficiency.

Host: Today we’re talking with Keicia Hutchinson about how to achieve a compliant query practice. Keicia has been in the healthcare industry for over 18 years and specializes in medical billing, Medicaid and Medicare auditing, and clinical documentation improvement. She is a member of AAPC and holds several credentials in coding, check out her bio in the summary for the full list. Welcome Keicia. It’s a pleasure to have you here today.  

Keicia: I’m excited to be here!

Host: Keicia, as you know, the clinical documentation improvement (CDI) process involves reviewing the medical record documentation for completeness and accuracy. It includes a review of disease processes, diagnostic findings, and supplemental documentation to ensure the patient’s medical history, conditions, treatments and outcomes are captured. It’s important to note that this is a collaborative process between health plans and providers. To start, will you paint me a picture of a day in the life of for the provider-health plan interaction and highlight some common challenges.  

Keicia: Yes, so to provide a little background, during the ACC risk adjustment era, health plans started to focus on chronic condition management. They realized they needed to be more in-depth with their documentation to support the diagnoses. For example, the medical record might say the patient has diabetes but didn’t provide anything further. So, the questions the health plans were asking were, “Ok, well, how did you treat it? What diagnostic tests did you run to come to that conclusion? How do you know the severity?” Of course, the providers had answers to these questions, but it wasn’t documented. In the coding field, there’s a mantra—not documented, not done.  

Host: What barriers do providers encounter with documentation?  

Keicia: Providers have busy schedules, so often times, providers see all their patients in the first part of their day and then go back for documentation at the end of the day. What happens is: while the provider is focused on hands-on patient care, things get left out of the documentation. So, it’s important to remember that the whole scope of the patient’s care includes thorough documentation. The patient might have a primary care provider and then individual specialists. All of those providers need to see the full scope of care so they can collaborate on behalf of the patient. That’s one obstacle. Another thing in the industry is that some providers have been reluctant to adopt EMRs. They prefer handwritten notes. Believe it or not, handwritten progress notes are still out there. The problem is that handwritten may delay the completion and thoroughness of documentation, as well as the timeliness of delivery for compliance and billing. Our clinical documentation platform resolves this problem because we have a feature that allows for documents to be uploaded. We believe it’s important to meet all providers where they are comfortable, and health plans need to work their process into the providers’ already existing workflow.  

Host: Let’s talk about queries. A query is a question that asks the provider about the care plan documentation. Once the provider receives this, they complete the documentation request with an addendum.

This is a critical component of CDI. We all know that even with the best efforts, things will get left out of documentation, or questions will arise and need clarification.

The query process allows health plans to clarify or request supplemental documentation to accurately reflect a patient's condition. It's not just about capturing correct coding; it's about maintaining compliance with regulatory standards while fostering collaboration between providers and health plans.  

Keicia, will you walk us through the communication process between health plans and providers?  

Keicia: Yes, let’s say we get a progress note from the provider. Previously, it was stated that the patient has diabetes. This is a chronic condition that requires ongoing treatment. What happens is, we’ll review the note to ensure it meets the regulatory requirements with the correct patient identifiers, everything is legible, conditions are documented and have supporting documentation. We might look for a prescription for diabetic medication, or an A1C lab test. We need to see that the condition was assessed and is being treated with a plan of care. If there is a missing component, we’ll send a query asking for further information.    

Host: With that in mind, how can health plans effectively support all types of providers—from the tech-savvy to the late adopters? So plans can enhance compliance without disrupting provider workflows?

Keicia: Great question. Like you said it’s important to fit into the providers’ workflow. They are already tasked with so much. Plans must give providers the tools and guidance they need to meet compliance standards without adding unnecessary work. It’s important to remember the overarching goal is patient care.  

And you’re right; there are all types of provider preferences. And some do prefer handwriting over direct entry into an EMR. Some prefer in-person provider coordinators who physically run the alerts to provider offices and serve as a resource. We also offer a middle ground between an in-person model and a full technology model. Providers can upload a document as a query response. This is a great compromise to allow printed hard copies and handwriting to live on but still capitalize on the speed of technology delivery.

In most cases, providers prefer the most efficient route that does not take them out of their EMR workflow. Our technology platform has a slider that emerges from the right hand of the screen and displays at the same time as the EMR. This way, providers don’t have to exit screens or go anywhere different. They are already in the EMR documenting, and the queries feel like a seamless extension of that experience. And there’s also a web browser option.

Host: I can see how speeding up turnaround time would also be appreciated by providers. You know, their brain is already on a specific case, so it’s probably easier for them to respond the next day versus having to recall an appointment that might have been 2 or 3 weeks ago.  

Keicia: Exactly. Also, a lot of providers enjoy the freedom to work independently when it’s convenient to them. With the in-person model, they have to allot an hour of their day to meet with the provider coordinator and then block time to respond to the queries. The whole process is longer. The industry is definitely moving in the direction of technology delivery, and as this next generation of providers move into the workforce, I think we will see a drastic reduction in in-person models. But, for now, I do think it’s essential to have multiple paths to the same end goal. Every provider’s office operates differently. Health plans have the most success with provider engagement when they offer different communication options to enable providers to close gaps, prioritize queries, and do so compliantly at the time of the visit.  

From a risk adjustment perspective, concurrent reviews yield the best results because it addresses documentation needs proactively. This reduces the need for retrospective corrections, which are by far the most administratively heavy and cost-prohibitive.  

Host: What kinds of barriers prevent providers from responding to queries in a timely way?  

Keicia: I would say the number one barrier is if the provider doesn’t understand what you’re asking for, they might move on to their next task and disregard the process. So, to this point, it’s important that queries are worded in a clear and concise way. We have a uniform template, so all the queries are asked in the same way. The questions are brief, simple, easy to understand, and open-ended. We are asking for the provider’s clinical judgment. Our job is to ask for clarification.

A second barrier might be if the provider gets an overwhelming number of queries to tend to. In these cases, it may be that the provider needs training on the query process to minimize the number of queries the provider receives. As a part of our review process, we need to evaluate the progress note to identify trends in provider documentation. So, if we see something on our end, we can reach out to support them. Maybe the provider's answers are consistently not corresponding to the progress notes, or maybe they’re answering the same way to a particular type of query or not providing the supporting documentation. We can identify whatever the barrier is and get the provider training and support for improvement.

Host: What are the most common query topics that you see?

Keicia: Legibility of notes is a big issue. Not to say that they’re all bad, but they’re not all good, either. The adoption of EMRs and technology platforms is reducing this issue, but believe it or not, it’s still a big issue.  

Another common query is the request for supporting documentation, or what we call in the coder world MEAT. It’s critical to help providers implement the habit of including meat in the notes.

Clarifications are also common. For example, the provider may indicate that the patient has COPD on the alert but documents Asthma in the progress note. Which condition is it?  

I think it’s important to call out that a provider has a different perspective than a coder because the job functions are completely different. As a coder, we won’t understand the biological foundations of why. Conversely, a provider does not necessarily look at the care plan from a coding, risk adjustment perspective.  

We have a few ways to address this. In the platform, we have tip sheets for the provider’s reference. At the top of each alert, there is a brief description that explains the response types in the CDI alerts and queries.  

Medical directors partner with us and are well-versed in both the coder world and the provider world. They have a huge role in delivering education, reinforcing the process, and supporting providers. They can interpret the query and help it make sense because they have both perspectives.  

Host: Will you help us understand the landscape of Compliance in Clinical Documentation? What kind of regulatory requirements impact the query process? And can you give some examples of non-compliant query processes and how to avoid it?  

Keicia: Absolutely! Compliance in clinical documentation is heavily influenced by CMS guidelines and AHIMA-compliance, both of which are critical to the query process. Our program ensures that all queries are non-leading, meaning they can’t direct the provider to document a specific diagnosis or treatment. For example, instead of asking, ‘Does this patient have congestive heart failure?’ a compliant query might say, ‘Can you clarify whether or not the patient has congestive heart failure given clinical indicators provided?’ This ensures the query remains neutral and encourages providers to document based on their clinical judgment and assessment.

HIPAA, on the other hand, governs the privacy and security of patient information. Queries must be handled in a way that safeguards this data—whether through secure communication platforms or ensuring only authorized individuals have access. For instance, sending a query via an unsecured email would violate HIPAA, whereas using a secure, encrypted platform designed for clinical documentation would keep the process compliant.

Common pitfalls in compliance include failing to properly document the query itself, which can lead to compliance gaps if audited, and overloading providers with unnecessary or irrelevant queries. To address these challenges, it’s important to align query practices with CMS’s Clinical Documentation Improvement (CDI) standards and ensure that all communication methods meet HIPAA security requirements. Regular training and audits can also help identify and correct any weak points in the process, creating a more compliant and efficient query workflow.

Host: Keicia, thank you for meeting up today. I think the take-home message is that the industry is shifting from a reactive approach to a prospective model by addressing documentation needs upfront. And in order to accomplish this goal as an industry, we need to leverage technology to standardize the compliance process which in turn is going to reduce the administrative burden on providers so they can document at the point of care and in a timely manner.  

Keicia: Exactly. And I’d like to add that it’s the role of the health plan to drive this initiative.  

Host: Absolutely. Keicia, I’ve enjoyed the conversation today.

Keicia: Me too. Thanks for having me.  

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