Description
Upon review of medical record cases, discussion of opportunities for documentation improvement of diagnoses and procedures regarding their level of specificity and presence on admission. Review of queries regarding potential fraud and/or compliance issues, conflicting diagnoses, abnormal findings, and post-discharge query opportunities. Review of requirements for documentation of query response, tracking of queries. Develop policies for documentation of query responses in the record to establish official policy and procedures related to CDI query activities. Develop policies regarding various stages of the query process and time frames to avoid compliance risk.