What does the RADV Medical Record Reviewer Guidance say about physician queries?

A lot. I’m summarizing it here.

See link below, p. 61, for the full monty. Short explanation:

• CMS conducts annual RADV audits to ensure risk-adjusted payment integrity and accuracy. They use coders to do this; the RADV Medical Record Reviewer Guidance guides their audits. Jan. 2020 is the latest version.
• RADV auditors are instructed to examine queries when part of the permanent medical record. If they are not part of the record, or submitted by a Medicare Advantage Organization (MAO), they are not acceptable sources for HCC submission.
• Auditors are instructed to audit queries for compliance based on AHIMA query guidelines. Meaning, a query should include the clinical indicators and not indicate the impact on reimbursement. A leading query is one that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or procedure.

Here are relevant excerpts.

Explanation/examples

When submitted with the associated medical record, diagnosis query forms that are completed, signed, and dated in a timely manner (i.e., within 90 days of the date of service) by the physician/practitioner and became part of the official medical record will be reviewed for validity and clinical consistency with the medical record documentation. For RADV, a coder or clinical documentation improvement specialist may query a physician/provider at the time of the encounter and the response documented and authenticated by that physician/provider is what is meant by a medical record query. The query form letter becomes part of the official medical record per that facility’s documentation policies. This is a standard of practice defined by CMS recognized leaders in health information documentation, AHIMA. Some MAO’s have adopted similar appearing MAO coder/physician “query” labeled type letters. Examples of these have been found in prior RADV audits added as unacceptable alternative data sources to their RADV submissions to attest to prior claim HCCs or additional diagnoses after the original encounter.

Reviewer guidance

Query type forms generated by the MA Organization or their coding staff contractors are not acceptable for review as part of the medical record. They are considered extraneous data from an alternative data source not allowed per Risk Adjustment policy. If the unacceptable query type form is the only source of the HCC, select a different record for submission.

RADV auditor action

Query forms will be considered on a case-by-case basis to determine whether the document is an acceptable standard physician query made by a coder or similar facility staff at or near the time of the encounter or if it is some other unacceptable late addition of conditions after the original encounter. RADV reviewer will not code from documents even if labeled (incorrectly) as “coder query” if the documentation is not generated at or near the time of the encounter by the facility or physician office.

References

Contract-Level 15 Risk Adjustment Data Validation Medical Record Reviewer Guidance:

https://www.cms.gov/files/document/medical-record-reviewer-guidance-january-2020.pdf-0